Welcome to the American Journal of Sports Medicine's webinar in conjunction with the American Orthopedic Society for Sports Medicine. Thank you for joining us. I'm Christine Watt, I'm the Editorial Administrator for the American Journal of Sports Medicine, and I'll be the operator for the webinar today alongside Donna Tilton, the Editorial and Production Manager for the American Journal of Sports Medicine. Before we get started, I would like to take a moment to acquaint you with a few features. There are options for how you can listen to this webinar. If you have any technical difficulties hearing the audio properly, please try clicking the phone call option and calling in for the audio or switching the speakers that are being utilized. At any time, you may adjust your audio using your computer volume settings. To send a question, click in the text box and type your question. When finished, click the Send button. Questions you submit are seen by today's presenters, and we will have a dedicated time to address your questions at the end of the presentation. There is CME available for this online activity. Here are the learning objectives and disclosures. At the conclusion of today's program, we ask that you complete a brief evaluation by going to education.sportsmed.org and logging in. Please take a moment to complete this if you wish to collect CME for this activity. At this time, I would like to introduce our moderator, Dr. Robert Westerman. Dr. Westerman is Assistant Professor of Orthopedics and Rehabilitation at the University of Iowa and Team Physician for the Iowa Hawkeyes. He is a member of the AJSM Electronic Media Editorial Board and will be moderating our webinar. And with that, I'll turn the microphone over. Thank you, Dr. Westerman. Yes, thank you, and I'd like to thank the AJSM and the AOSSM for allowing us to put on this webinar at a very important time of year, as many of the attendees and panelists are very involved in sideline coverage. And it's very important to keep up to date on the most important aspect of these sideline emergencies. And I'd just like to thank all the panelists as well. Our panelists are pictured here. Kurt Spindler, who developed the Sideline Guidelines app. Kurt is the immediate past president of the AOSSM. He is at Cleveland Clinic, Florida, and he's the Director of Research. And he has 25 years or more of Division I football coverage with Vanderbilt University. Latul Faro is next. He actually has a family medical emergency that he's dealing with today. He'll be unable to join. Grant Latul is the previous Cleveland Browns team physician, team doc. He's the Fellowship Director at Cleveland Clinic and the Director of the Sports Medicine Clinic in Cleveland. And he's also the team doc for Baldwin-Wallace University Athletics. Next, Tishon Lynch. Tishon is one of the vice chairmen at Henry Ford Hospital. He is the team doc for the Detroit Lions. And he's going to be giving us some NFL perspective for this talk. Just as a background, I think the first time I really started hearing a lot about sideline issues was when Ned Amendola gave us a presidential address for the AOSSM. He discussed what the environment is like on the sideline, where decision making comes from, and the importance of protocols as regards to keeping athletes safe and healthy. I would just like to acknowledge this slide provided by Dr. Amendola that gets to some of the intricacies with decision making along the sideline and highlights the importance of teamwork and also protocols and procedures to keep our athletes healthy. So we can advance slides now. So, as I said, Latul unfortunately had an illness in the family and he'll be missing tonight. So, I'm going to go over his slides for the webinar tonight. So, this is basically the meat of the medical aspect of sideline coverage of c-spine, abdominal, airway, and cardiac emergencies in terms of sideline management. These are his disclosures. So, first is the keys to success. So, it's all about being prepared. You know, when you're on the sideline, anything can happen and probably will, and catastrophes rarely occur in ideal circumstances, and preparedness requires practice. So, one of the most important things that Dr. Farrell preaches in Cleveland and we use at Iowa is to practice in the environment that you'll be covering with the personnel that you'll be working with and develop an emergency action plan. First is c-spine injury. So, when do you suspect a cervical spine injury? Well, it should be suspected in any unconscious athlete. Athletes with more than one limb presenting with numbness or weakness, obviously with paralysis, midline spine pain, or step-off, or severe neck pain. C-spine and spine boarding is very important as well. You have to know your medical team, athletic trainer, primary care, sports medicine, and orthopedics. You have to know who's doing what, and this should be determined in a pre-season meeting where you define everybody's role and you should practice the process of spine boarding knowing the equipment that you have and the backup you have from an EMS perspective. Ensure that you have necessary equipment and personnel, including EMS, spine board, stabilization equipment, and face mask removal tools. The next decision tree you have to make with your team is, are you going to c-spine, are you going to spine board with a log roll or six-person lift? You have to know what equipment you have. In terms of the log roll, you need five people, one in the head and the body, and one manning the spine board. If you have enough people for the six-person lift as shown here, it's preferable, but you need up to eight people, head, body, and spine board to stabilize patients for this procedure. It really depends on your manpower and what you have available, but come up with a plan and be prepared to do whatever stabilization procedure you need to get an athlete on the spine board. You have to know your equipment, what's going on and off. All or none in a lot of circumstances, the face mask always comes off and you have to know your tools. Athletic trainers, equipment managers are good people to refresh with at the beginning of the season to know who has the tools to remove a face mask if necessary. All or nothing refers to the helmet and shoulder pads, you're either going to take both of those off or you're going to leave both of them on. Those decisions should be made on an individual team basis. Then where's the athlete going? You want to have them going somewhere that you know, and you want to know how to package the athlete up appropriately for their arrival at the ED. C-spine injuries and return to play, if you have some sort of fracture in the C-spine that's treated non-operatively with no neurologic deficit, that's a three to six-month recovery and return to play. Transient neuropraxia can return as early as four to six weeks. What about cardiac emergencies? There's arrhythmias, there's myocardial infarctions. Cardiac arrests is obviously seen with sudden collapse, pulselessness, and apneic athletes. There are also some subtle signs of early arrest, including palpitations, dizziness, lightheadedness, and chest discomfort. Cardiac events should be preceded with a history, you have to find out if the athlete has any heart issues, what the duration onset and severity are. Physical exam can include taking a pulse, seeing how fast their heart rate is, seeing if the heart rate is regular or irregular, looking at the blood pressure and breath sounds. And treatment should include monitoring IV, and most important, transport to the ED for definitive care. Sudden cardiac arrest or collapse with no pulse, the single most important factor for good survival is CPR followed by early defibrillation. So if you're going to save one life on the sideline, it's going to be with an AED for the most part. You have to know where this AED is kept, you have to know how to use it, this should be something you go over with your athletic trainer and your team before the start of any season. But know where it is, know where it's kept, know how to get to it and use it. So if you're in a situation where you do have a cardiac emergency and need to start CPR, first call 911, then perform chest compressions by pushing hard and fast, so more than two centimeters in depth, 120 beats per minute, allowing for recoil between compressions. 30 to two is still a reasonable estimation in terms of breaths, or chest compressions to breaths. You want to minimize interruptions between compressions and you want to have a team that can rotate every two minutes to provide compressions. We're about to return to play, so hypertrophic cardiomyopathy, no arrhythmia, depends on the diagnosis and commodity of cortis, it really depends on the post-cardiac evaluation. So these are more higher level and not same-day game return decisions. What about airway emergencies? Doc, I can't breathe. The most common thing on a football or soccer sideline is going to be asthma, but there can be other issues with breathing, including pneumothorax, pulmonary embolism, especially if your team is traveling long distance, like transcontinental flights, cardiac issues, if the player has an arrhythmia history, and also coaching issues with cardiac problems, because coaches can have heart attacks, arrhythmia is a heart failure, and the coach is part of the team we're looking after as well. Airway emergencies, what about asthma? You have to know their history, you have to know that you're players, you have to know what their past treatments and hospitalizations were for, physical exams, you look for wheezing and prolonged expiratory phase where they can't get air out of their lungs. You try rescue inhaler breaths with albuterol, two puffs times two. If they can't regain function of their lungs and they're still wheezing, they need to be removed from play. What about pneumothorax? This can be sudden, with sudden onset shortness of breath, it can also be traumatic after a collision, or it can be spontaneous, although this is less common in athletes. The physical exam would be diminished unilateral breath sounds, tension pneumothorax would be presented as a calm or a clammy, cool, very distressed athlete with lowering blood pressure and trachea deviation to one side. In rare cases, you can use a tension-sided decompression with a 14-gauge catheter in the second intercostal space, and this should only be in a crashing patient with a clear pneumothorax, with absent breath sounds on one side. Most of the time, if you suspect this, just get a little oxygen on them and get them to the EDS as fast as possible. What about airways and return to play? If asthma can be treated with no wheezing, you can consider having them play as tolerated pneumothorax can take four weeks to be able to return safely, and if you're traveling with your team, there's generally a no flying for two to four weeks recommendation, so this should all be considered when arranging your team's travel after an airway emergency. What about abdominal injuries? This would be a direct blow to the abdomen, a deceleration injury. You want to know about history of mononucleosis or worsening abdominal symptoms over time, so a good case of sideline and monitoring. This can be spontaneous in cases of mononucleosis. The exam would be tachycardic. There would be very low blood pressure. There would be a rigidity and rebound on the abdominal exam. Left upper quadrant, think spleen, right upper quadrant would be a liver laceration. Both have happened multiple times in football games. The back percussion or low back could be a sign of a kidney injury, and epigastric pain could be a signal of a bowel laceration, but splenic ruptures, they're generally treated non-op and return to play is sort of three to six months. If they're operatively removed, you can return as early as around a month. Liver lacerations are a three to six month recovery with normal liver function. Bowel injuries and kidney injuries, two to four to six weeks, depending on follow-up exams with our general surgery colleagues. What about post-emergency, so you've seen the emergency, you want to call ahead to the emergency department or hospital. You have to have a plan for EMS because your EMS that was on the sidelines needs to be replaced with another squad, so you want to make sure that's being coordinated. Most importantly, you need to gather yourself because you have a bunch of athletes in the field and the game's going to go on and you still have a job to do. After each emergency, especially when the bus comes out and you package an athlete up to go to the ER, you want to debrief with your team, you want to acknowledge what was done correctly, where is there opportunity for improvement, and what can be done differently in the future to help expedite care and improve care for the athletes that we're seeing. So in conclusion, sideline emergencies are not common, but they will occur during your career if you're covering high school, college, or professional games. Preparedness is key, and you need to have an emergency action plan, and this needs to be communicated with your team. You need to practice these procedures with your team, especially log roll and lifting prior to the season, and when in doubt, if there's any injury to an athlete that you're unsure about, just send it out. So thanks for your time, and we'll move along to the next presenter. We'll have Kurt bring up the slides, so I don't know if Donna can bring up Kurt's slides. All right, thank you, Robbie, thank you, Robbie, very much. So give a little talk about sideline guidelines, musculoskeletal aspects, next slide, disclosures that have already been shown, next slide. So decision-making really occurs for the team physician on the field, in the training room, must decide on what's the status for the next game or in the office, next slide. It's really an art, not a science, there's no huge textbook, there's no large prospective database or no randomized trials, and so medical decision-making is art, and it's really carried down by a few people that have done it at a big level, either in major competitive sports in different leagues and at different competition levels, and it comes down to, is the athlete safe, can the athlete perform the sport-specific activities required of their position and their competition, and then how do you assess the risk of re-injury, and what's the consequence of re-injury, next slide. So some of the principles are that you need adequate range of motion of a joint, their neurologic involvement needs to be by and large intact, you can recover from a stinger either quickly during a quarter or half or maybe not at all, you need relatively normal strength of the upper extremity or lower extremity, and that can be done by manual motor testing first, then simple functional tests and simple sports-specific tests, and then finally, can you protect the injured area from the risk of re-injury, and that's really to understand the risk of re-injury would be, what it would mean to the treatment plan, and finally, is the willingness of the player, are they confident in their ability to return, next slide. So Sideline Guidelines is an app that was developed, it's purely educational, there is no royalties or profits or anything that gets paid to anyone for this. If you look at it, there are 36,000 high schools in the United States, there are much, much less than 10,000 fellows who train sports medicine, orthopedic and primary care providers, so you have to wonder, there are a lot of people out there that don't have the same training and maybe not the same knowledge base to do that, so the app can be effective. And finally, the practice on a competitive, as I've said before, is an art rather than a science, because there are no large enough sample size in cohorts or the ability to randomize large amounts of evidence, in fact, if you ask me a question regarding what do we know about ACL reconstructions in the elite athlete, we don't know much, even in Moon with 3,500 ACLs, less than 8% would be considered elite athletes. There's no textbook, there's no course, there's no effective learning vehicle that had been established and the learning vehicle now is the fellows course that we have, maybe some of you have attended that for AOSSM at the beginning of the year, and on fellows when they begin to train on day one, what's the first thing we do, we put them on the sidelines, without any tools or education. Next slide. So this app is unfortunately only available on an iPhone because it has to be programmed differently for an Android. It's knowledge at your fingertips, you can download it for free, this is the way it looks. When you appear it and when you see it, it looks like this, type in sideline guidelines, download the app. Next slide. It has sections on it from any sudden cardiac death, the pulmonary emergencies to orthopedic emergencies as well. Next slide. And it creates an organized plan, there may be over 180 different situations you can get caught in. It'll describe the history, the physical examination, it'll talk about what x-rays show you, what's decision making, when can you return to play, what about game day treatment, and we'll go over that in a few musculoskeletal injuries. Next slide. Just as a smattering to see how that would work, if you had someone with a knee injury, one of the big decision makings, you're going to have to decide whether this is an ACL injury or whether this is something that is a blow to the side of the knee that winds up being a grade one or grade two MCL. And the situation obviously is very different. In an ACL injury, 70% are non-contact, you may get fluid right away, you may be able to determine a lockman, it's probably unlikely for a pivot shift on the field. For an MCL or on the side of the field, you want to judge whether it's stable in extension at zero, whether there's some laxity at 20 degrees, or whether it's unstable in extension in grade three. Next slide. So obviously an ACL, you would not let return to play for that game, they would not be able to function, and game day treatment obviously would be simple things, rice and crutches to further treatment, obviously an MRI, and then further evaluate the injury. If you had an MCL treatment, if it's a grade one, they may likely go back, particularly if you have a brace on the sidelines or taping on the sidelines, it gives you some stability. If they're a grade two, it's much less likely they'll go back unless a brace really is effective and the grade three is not going to go back. Can you go back a slide, Donna? So what about an ankle? A lot of injuries you worry about in an ankle would be a direct trauma to the ankle or twisting mechanism with a fixed foot that can wind up being an ankle fracture or a syndesmotic injury versus a routine ankle sprain, and versus a snap or a pop when someone's jumping or cutting on the lateral side of the foot where you're worried about a fifth metatarsal fracture. Again, the ability to examine the exact site of pain is really important for syndesmosis or any ankle fracture. An excellent test is a external rotation stress test that's positive. It usually means they have a fracture and or a syndesmotic injury. And finally, in a fifth metatarsal, you're looking for pain right at that base. Next slide. And so obviously, if there's a simple ankle sprain, they could probably go back. If it's a fracture, no, and if it's a significant high ankle sprain, they also probably will not go back. Obviously, a fifth metatarsal, someone who has pop fat at the time when they're jumping or splinting is not going to go back. You're going to use splinter crutches. Next slide. If we shift to the upper extremity, common shoulder injuries are very common. They can range from an AC joint sprain, which would be a direct trauma or fall on the lateral aspect of the shoulder, or they can be a shoulder dislocation that can result from trauma or a fall on an abducted arm. The examination would be very different. The key to a shoulder dislocation is you'll have no external rotation of the arm because the arm is out of the glenoid. You'll also have limited internal rotation. Versus an AC joint sprain, you'll be point tender on a distal clavicle, and they may actually be tender on the CC ligaments depending upon the degree of the type of AC joint sprain. Next slide. So if they're a type 1 or type 2, they may go back. Type 1, obviously, probably can go back more, particularly if you can protect it and have some padding underneath it. The big question on a type 2 depends upon the level of competition, where they are, whether that individual athlete, whether you can inject that athlete to play or not. That's really dependent upon the relationship of the team physician with the competition, whether it's in the NFL, whether it's in college or high school, unlikely to do it at high school. For shoulder dislocation, obviously, in their arm, by and large, 99% of those are not going to go back. Back one slide, Donna, please. So other injuries that are very, very common are wrist injuries and finger injuries. And so commonly, they fall on a hyperextended wrist. And one of the key factors, both for wrist and finger injuries, is their inability to have a power grip, to have a weak grip. They may or may not have a lot of localized pain or tenderness, but they don't have grip. And considering that a lot of these athletes, particularly if it's in a power sport, will have a really, really strong grip, the fact that they can't crush your hand means something's going on. Not good. For a finger, there could be some deformity. It can be, I just jammed my finger. Again, you may or may not have point tenderness or crepitus or inability to have a power grip there. Next slide. If it's a wrist brain, and you can protect it, they can go back. It makes a huge difference whether they're, if they're a running back or they're a receiver or if they are a quarterback, then if you can't really splint or protect it well without interfering with their position, they may not go back. But if there's certainly alignment, a linebacker where you can, they may go back if it's a wrist brain. Depends on the degree and the amount of pain. For finger fractures, it's entirely dependent upon where it is and what time. Sometimes you can, small fractures or fractures that occur initially that you don't know about with a dislocation may be able to go back with a body tape and splint. The key thing is that all finger injuries need to be x-rayed after the game. I have not been able to figure out, nor has anyone helped me figure out, which finger that looks fractured is fractured and which finger that looks not fractured. Winds up having a fracture. So it's very, on examination, I know no way of distinguishing it. And so what you want to do after any significant finger injury, whether they go back to play or not, is get an x-ray. Because what you don't want to have is a finger that's swollen four to six weeks later and find out you had a chip of the condyle or a displaced fracture and now there's nothing you can do. So thank you very much for the opportunity to speak. Thank you. Thank you, Kurt. That was a very great overview of the very common musculoskeletal injury patterns we typically see in the sidelines in football. I'd also like to thank Kurt again. He's giving this webinar at 2 a.m. from France. So we're very graciously lucky to have Kurt who developed this app to give this talk for us. So thank you very much. Next, we'll move on to the next slide. So next, we'll move on to T. Sean Lynch. Again, he's the head team physician for the Detroit Lions. He's the vice chair at Henry Ford Hospital System just outside of Detroit, Michigan. He's going to talk to us about lessons from the NFL, concussion management for the football athlete. Great. Thanks so much, Robbie. You guys can see my slides here all right, correct? Yep. Okay, perfect. Okay. Here are my disclosures, none of which are relevant to the content of this talk. I will disclose as we have talked about, as Robbie introduced, I am the head team physician for the Detroit Lions. But with that being said, I certainly have a broad spectrum of experiences as on Sundays, I might be on the field at Ford Field. But on Friday nights, I cover Cannes High School, which is a Division I high school here in the suburbs of Detroit, the largest division. And certainly an interesting dichotomy of experiences between covering a high school football game with one athletic trainer versus several with multiple physicians on the sideline with me on Sunday. And then also my past life at Columbia, I was the head team physician for Fordham, which is a Division I school in the Bronx, but 1AA or FCS, and is recently ranked in the top 20 in the country. So proud to see that the Rams are doing well. So let's start off with an illustrative case. This is an 18-year-old college freshman with head-to-head contact. Of note, he did have one previous concussion when he was in high school, in which he missed one game, had a relatively straightforward return to play with no prolonged symptoms. However, with this specific event, he had dizziness for about 10 minutes and then light sensitivity for about 10 days. We're going to look at this video here. We're looking at the all 22 from up top here, where my mouse is coming in here. You can see we're going to be focusing on this player right here. We'll have a zoom-in film here in just one second here, but wanted to give you the broad spectrum. But if you focus here, you can see that this athlete's going down onto his knees. When we zoom in, we're going to be looking at this athlete right here. He's going to be coming through a gap there and has a relatively benign hit to the head and goes down to his knees soon thereafter. Several days, I'm sorry, he was continuing to have lingering headaches and wasn't able to be progressed to the protocol. So we'll take a pause right there. We'll come back to this case here at the end of our discussion. So what I want to talk about is what is a concussion? It's a pretty loaded topic. We'll try to do it in two slides. I know some individuals have written textbooks on this and have done PhD dissertations, but I think for our sake here tonight, I tried to distill some of the current information into two slides and we'll talk about more practical information. In a nutshell, sports-related concussion is a traumatic brain injury induced by a biomechanical force. And some common features that you'll see is a direct blow to the upper extremity that creates an impulsive force that's transmitted to the head. Individuals will have a rapid onset of short-lived impairment of neurofunction that resolves spontaneously. However, these signs and symptoms can evolve for minutes to hours. So this is not an uncommon thing where we can see an athlete take a hit, they feel fine, and then five to 10 minutes later or post-game start developing symptoms that might be consistent with a concussion. These acute signs reflect a neuropathological change due to the functional disturbances as opposed to structural injury to this central nervous system. And there can be a range of clinical signs and symptoms with resolution following a sequential course. However, there might be some symptoms that might be prolonged, such as our illustrative case that we're talking about. Some of these potential concussion signs that we should be on alert for are loss of consciousness, fencing posture after being hit, slow getting up from the ground with motor imbalance, a blank look to the eye, potential disorientation or behavioral changes, amnesia, whether it's retrograde or antegrade, clutching of the head after contact, or any facial injury in combination with any of these aforementioned concussion signs. In terms of the potential concussion symptoms, headache, dizziness, balance issues, nausea with cognitive slowing, sensitivity to both light and sound, disorientation with tinnitus or vertigo. Now, for those of you who might be novice on the sidelines, you might be looking at us, how are we possibly going to be able to diagnose, or I'm sorry, recognize, let alone diagnose these athletes who have these traumatic brain injuries, particularly when they're running at each other at high rates of speed? Well, I'll be honest with you, it really does take a village. And it's not this village here that we're talking about, the village people, but it really does take a squad. And at the NFL level, we have numerous medical providers that are with us on the sideline. But on the high school level, it's utilizing all the resources that you have available, including your athletic trainer. On Friday night, I might have a chief resident or fellow with me. But making sure that you're educating your coaches and making sure that family members are on alert. At the college level, depending upon what level it might be, you might have a wide variety of number of athletic trainers. But that can certainly be more, the more eyes that you can have on the athlete, the better. But with our experience with professional football, we certainly have quite the squad that helps us. And you'll see some of this alphabet soup here on the right hand side, the UNC, that is the unaffiliated neurotrauma consultant. And we actually have three of those on any given game day. This is a physician who's trained in either neurology, emergency room medicine, is a primary care boarded sports medicine physician, or a board certified neurosurgeon who manages acute trauma. And these individuals have significant training, both within the season, as well as after the season, to help them with the recognition of these head injuries and helping the management on the sideline on game days. The VTML, this is the visiting team medical liaison. I put this here because they will serve a backup role in the event that the UNC might be pulled, in the event that there's multiple concussions going on and they get pulled back to the locker room, the VTML can be of assistance to be a backup. But also this is an individual that as soon as a visiting team arrives in the market of their weekend game, they're at the disposal of the visiting team for any medical needs that they might have. There's been lots of issues over the last 10 years or so with medications with teams that are traveling. So being able to utilize this VTML can be incredibly helpful to help us navigate when we cross state lines. There's been a lot of legislature as of late as well too, with advocacy from AOSSM, as well as AAOS, as well as the non-office sports medicine societies, protecting physicians who are going on the road. But I think the most important thing, and this is a little bit of a sidebar here, is just making sure that you know the state rules of where you're traveling with your team, whether it's with your high school, college, or if you're covering a professional team. Getting back on track here, in terms of the booth ATC spotters, there will be two ATC spotters, eyes in the sky is what we call them, and there will be one for each team that will be in constant communication throughout the game. You'll see that the team physicians, as well as the athletic trainers will have earpieces in and they'll be in constant contact with these ATCs who will be watching the game in real time, will have multiple views and be able to assess for any potential questionable hits and at any point can call for a medical timeout or ask for us to evaluate any athlete. And you might be asking with all these individuals, there might be a lot of cooks in the kitchen, and how do you get everyone on the same page in a relatively quick manner when you're in a very chaotic environment? And that's where our 60-minute meeting comes into play here. And that includes the head team physician, both the orthopedic as well as the primary care physician, as well as the head athletic trainers for both clubs, all three UNCs, one on each sideline, the one that will be up in the booth, as well as our ATC spotters. There is a lead EMS individual who will be at the sideline for the games as well. We'll have a meeting with the referee, our VTML, as well as our airway management physician. And this is a protocol or standardized meeting in which we have an introduction of all the medical individuals. And this will be the referee will come for the first couple of minutes just so that they can get an introduction to each of the head team physicians as well as the ETC so that they can put names and faces to each other in the event that anything occurs in gameplay. And then once the referee steps away, then we go through the logistics of where the ambulance will be, where the transport card is, whether or not the visiting team brought a spine board, and if they want to use ours, where the defibrillator as well as where the advanced airway equipment is. We review our emergency action plan medical facilities. And for us here in Detroit, it's at Henry Ford Medical Center, which is a level one trauma center, which is six or seven minutes by light and sirens from Ford Field. And we're able to bring anything emergency medicine based or orthopedic or spine related. We also review where the x-ray machine is within the building. And then we verify who's going to close the loop. And there's one designated individual for each team who will close the loop with the booth ATC spotter in the event that there is someone that they ask for us to evaluate for a concussion. And the one thing just to highlight that was already mentioned earlier in terms of our emergency action plan, this is something that we review in our off season. We practice, we have scenarios, we have a whole day of scenarios where we practice different scenarios under the guise of athletic trainers from the NFL to ensure that we are prepared for any worst case scenario that might happen. And this is just our opportunity just to synthesize this within a few minutes before we get out onto the field for warmups. Now, this is what our concussion game day checklist looks like. And I think that this actually does a pretty good job of breaking this down pretty easily to help anyone, whether you are covering a sideline on a Friday night with your high school team, Saturday for your college or on Sundays. And we'll work through this together here real quickly, highlighting some important features and then we'll talk about the return to play. So if you look at the top of the checklist here, you'll see that there's a question of an athlete who receives an impact to the head, and they have any symptoms that are concerning for concussion or stinger, or at the ETC booth that calls up, they will be immediately removed to the sideline and stabilized on the field as needed. And then we'll do our quick sideline survey. What that includes is removing the helmet. And this is something that we'll do in conjunction with our unaffiliated neuroconsultant. We'll go through our four no-go events. So the no-go is loss of consciousness, gross motor instability, confusion, or amnesia. You'll see that on the right-hand side right there. And if any of these individuals have any of these symptoms, then they are automatically removed from the game. We'll go through the history of the event and what this individual experienced. We'll go through some, we'll see if they're experiencing any signs or symptoms. And then we'll go through the Maddox questions. So this is a series of five questions. And five questions, which you'll see here. What venue are we at today? What half is it now? Who scored last in this match? What team did you play last week or last game? And did your team win the last game? This will give you a sense of cognitively where the athlete is in terms of space and time. And then if there's any video to record, we'll go through that. And then if there's any video to review, we'll certainly take a look at that. In addition, we'll go through a brief cervical spine exam, evaluate their speech, look at their gait, and look at their eye motion. If everything looks good and they have a benign video, we'll allow for them to return to play. However, if there's any elements that are concerning, we'll then bring them back to the locker room where we'll then go through a more formalized exam in the form of a SCAT and go through a complete neurologic examination. And one thing that I'll highlight here in terms of our SCAT examination, for those of you who are not familiar with doing this test or have not done it before, I would try to practice this several times before you cover a football game. The more familiar you can get with this, the more facile and the more efficient that you will be with doing this. This is a very complex test with a lot of moving parts. And the more comfortable that you can become with it, the more comfortable and the better off that you will be. Now let's talk about return to play. This is always a topic of conversation here. So this is broken up into five phases. And at the NFL level, phase one is symptom limited activity. At this point, we'll avoid any physical or cognitive activities that will increase an athlete's symptoms. May engage in activities of daily living, such as limited stretching and balance under the supervision of the medical and training staff. They'll undergo some light aerobic activity and tolerate meetings if possible. And if there's not an increase in symptoms, then the athlete can be progressed to phase two, which is aerobic exercise. At this point, the athlete should be returning to their baseline level of symptoms. They can begin graduated cardiovascular exercise stationary by treadmill with dynamic stretching and balanced training. The duration and intensity may increase as long as the symptoms do not return. Phase three, this is the football specific exercise phase. They can continue their sport specific activities as well as supervised strength and training. They'll be allowed to practice with the team in a sport specific fashion for less than 30 minutes. At this point, they can either at phase two or phase three, they can then return, I'm sorry, they can complete their neurocognitive training. So they will have baseline neurocognitive testing that they have done. Testing that they have done. And this can be done either during the second or the third phase. And this will need to be interpreted by the neuropsychology consultant and cannot proceed to contact activities until the testing is at the baseline level. Phase four, this is non-contact training drills. So they'll continue their cardiovascular training with strength and balance, as we've mentioned in the previous phases, but now they can start throwing, catching, running and position specific activities. All signs and symptoms and neurologic exam must return to baseline before they can return to full football activities. And then finally phase five, this is the full football activity clearance. So at this point, they must be able to demonstrate the ability to participate in non-contact activities, including meetings, conditioning and non-contact practice with no recurrence of symptoms. However, I'm sorry, and if a patient can tolerate full participation of practice and contact without their signs and symptoms, then they'll be at that point considered to be cleared for full participation. Now, let's go back to this case here. As we showed you here earlier, college freshmen who had a relatively benign hit to the head during practice with prolonged symptoms. This was from about five or six years ago, at which point in terms of how we progress patients through the return to play protocol was at a little bit of a different pace than what it is now. Symptoms, there was at that time trying to wait until symptoms went away before allowing them to start some exercise. However, there's been a lot of good research that shows that some gentle exercise can actually stimulate healing. However, in this case, the athlete continued to have headaches. We did have him see one of our neuropsychologists at Columbia who was able to get him on a vestibular ocular training program that he would do a series of eye strengthening exercises as well as some meditation work. And it took him about two to three weeks for him to have an elimination of his symptoms. And he was able to return to play about four weeks after his initial onset of his injury. And then the last thing I just wanted to mention here, as you can see in these pictures here, you might notice that the athletes here might, as I circle here, have these black caps on. So about six or seven years ago, during the first generation of the guardian caps, we utilized these at Fordham as we were having an increase of concussion in our alignment. And anecdotally speaking, as we started to utilize this, that number went down considerably in this past year during training camp, the NFL instituted a policy that offensive and defensive alignment as well as tight ends, as well as linebackers had to utilize the guardian caps during training camp. And it was found that concussions in this population dropped by more than 50%. And actually 50% of the concussions that they had within this group were actually concussions where it was face-to-face, where the metal cages are. And that's where the contact occurred, which you wouldn't be able to get that contact, or I'm sorry, a guardian cap would not be protecting. So it'll be interesting to see how this is utilized here in the future. But in these athletes, where there's a lot of head-to-head bumps during training camp, there was some relatively, some great information coming out that hopefully we'll be able to utilize here for the future. So in conclusion, when covering the sideline, since it's important to be on high alert, making sure that you're being aware of your surroundings, particularly with high hits. This isn't the time to be taking phone calls or checking your cell phone, unless there's a medical issue that's going on. Everyone really is a participant in the care of the athletes, particularly on the sideline, trying to make sure that we're diagnosing and preventing these concussions. I think it's important to note that O2 concussions are the same. I think our illustrative case really shows that in this particular instance, this is an athlete who had a relatively benign hit, but had a prolonged recovery. And there's those individuals who can have significant head-to-head contact and can have no symptoms or no concussion, or might even have a relatively straightforward concussion where they're out of the protocol within a week. It's important to note that communication is key. I think these are instances where over-communication is important and making sure that you utilize your resources that you have available, particularly if you're covering a high school where the athletic trainer might have more day-to-day contact with these athletes and know their personalities. So kind of lean on them to help lead you down the path of righteousness, to let you know if there's any behavioral changes or if things don't seem right with an athlete. And then finally, when it comes to the actual examination itself, practice, practice, practice. The more comfortable you can get with your concussion evaluation, the better off you're gonna be and the more efficient you'll be. Because whether it's the high school or the NFL level, people will wanna know immediately what is going on with this athlete and what is the next step. So the faster and more, or not necessarily faster, but the more efficient that you can be and the more comfortable you are with these tests, the better off. So thank you very much. Thank you so much, Dijon. That was a great overview of your perspective from the NFL side of things. I think it's really important, the work that has been done in the NFL because they're under such a magnifying glass, but the lessons that you guys can share with us that can help us out at the collegiate and the high school level are very important. So Kurt and Dijon, if you wanna join me, we're gonna go over just a few rapid fire cases just to kind of highlight some of the intricacies of these injuries that we have seen here. The first one will be NFL regular season game, six minutes before halftime. The starting defensive back comes to the sideline, has a right middle finger PIP, volar dislocation. You reduce it and then you realize that it's open. So maybe you pull it back in with the glove on and then you realize there's some bleeding and you realize it's an open PIP dislocation. The x-ray demonstrates, or the fluoro demonstrates a reduced PIP joint with no fracture. So open dorsally PIP joint, midline Dijon. Kurt, what are your thoughts? Go or no go for returning to this game? Yeah, I'm happy to go first. So this is a particular instance that, knowing your athlete, well, quick answer, go. These are athletes who wanna be playing, if it's a relatively simple laceration, this might be something if there's enough time at halftime, you might be able to try to wash out quickly and get some sutures just to provide some provisional fixation. And then you said it was a defensive back? Correct. So someone that could be clubbed up or put into a protective hand supportive device. So that they can continue playing. You know, defensive backs would typically do fairly well in a club and prevents them from holding and getting past interference. But in terms of the open part, I wouldn't be that worried about it. And something that could be, you know, addressed post game, if there's still any issues with the wound. I think it depends upon what you mean by open. I mean, if it's a big laceration and a gash and the finger is unstable, that's not something that you probably let them, let that person go back in unless there was some dire circumstances. Where if it's just a pinhole, that everything else appears to be relatively stable in there. And I think you can let that person back in. Sometimes it's very effective in the middle finger, depending on the athlete. It's very effective just to buddy tape it to the index finger. And that may be all you need initially to let that person go back and play. Yeah, and I think your level of splinting really probably is dictated by how stable it is once it's reduced. So if it's, you know, really unstable, a very protective splint or pulling them out is probably right. But if it's fairly stable, once you reduce it, yeah, buddy taping is certainly reasonable. In the open part. Sorry, go ahead. The open part, I've heard about it, but I've not seen it. I've seen a lot of PIP dislocations in 31 years. And I've not seen an open one yet. So in a PIP dislocation, I think if you can reduce it, it appears to be they have flexion extension of their finger. I think then you can let them go back and play. I think you really have to worry about, you really have to make sure that there's not a central slip injury, where that you have to be able to assess that in the training room, because if the central slip is torn, then that's something that has to have a discussion whether you repair that or not afterwards in the next week. And just the one thing to highlight is the position of the athlete. There are some positions that will be more tolerant to be able to come back after that type of injury than others. Those athletes that are not gonna be depending upon their hands as much, whether it's an athlete that's gonna be catching or an athlete on the lines where they might use their hands for grappling purposes. Those athletes might have a little more of a difficult time in the acute setting to be able to work through that. So just something kind of beyond the open versus closed component of that. Sure, great point. Division one, so case number two, division one, collegiate road game, first quarter, starting quarterback, the first time anterior shoulder dislocation, non-throwing arm. So treated with a closed reduction. So where, so shoulder of your starting quarterback, Tishon comes out, are you gonna run out with the ATC and try and put this back on the field? Are you gonna put him in your tent on the sideline? Are you gonna bring him in the training room? You're on the road here. So what, first off, Kurt and Tishon, where are you gonna reduce the shoulder at? Well, I think you get one shot on the field to be able to try it. And my experience has been that it's usually a coin flip. If it wants to go back, it'll go back easily. If it does not, then you need to kind of get them into, whether it's in the tent or back in the locker room in a relatively protected environment before everything starts to season up on them. I would say that individuals who might go back a little bit earlier or a little bit easier are your multi-dislocated athletes. That might pop in a little bit easier. So, you know, you kind of can get, try to get your hand in there and maybe try to actually rotate the arm and see if that might, you might be able to guide it in. But try not to make a show of it because pretty quickly everyone's gonna have their phone out if it looks like you're pulling on the arm on either on the field or on the sidelines. So I try to get some privacy, whether it's in the tent or in the locker room. And then, you know, maybe I'll, you know, Kurt can comment on whether or not to let them play and I can piggyback off that. Awesome. So you go back to, go ahead, Kurt. No, I've not had success, even just in the quick attempt on the field. I've always done it in the training room. Those are where you can do it any place where you're not in the eyesight of the entire crowd. The TV crowd or whatever you want to. Then it usually does go back in. Letting someone go back in first time dislocator, they have to meet the, they first have to meet the criteria that their pain's under control, that they have relatively good range of motion and good strength of their arm. And that's only, I've only seen that happen once in 31 years. So it is possible. It's extremely, extremely light. You're gonna let that person back in again. Again, if you're gonna let them in, you're gonna have to protect them in a harness or something so they cannot get their arm in a position where it can easily come out. Yeah, that's a really good point. And I'd also like to add that this is a conversation that can be had with your medical team right now, or even before the season starts. How are we gonna manage a shoulder dislocation? You want to try once in the field, you want to move them back to the tent, you want to move them to the locker room. So this is clearly communicated with our athletic training staff. And so we have a plan for this scenario. So we're not just trying to try and wing it at one time on the field or whatever. But it's good to have an open communication and a plan with your team in terms of what you're gonna do in this scenario. Because it probably happens at least once a season. I think Tishon brought up a good point that you described the first time dislocator, but what about the recurrent subluxer, right? Or someone that's subluxus posterior anterior, or this is the fifth time this person's come out anteriorly. Those are all situations because of the frequency and the less trauma required to coming out, they're more likely to go back and play because they're more likely to regain and cover real quickly. And then it becomes a problem. The problem then shifts to what do you do with it at the end of the season? Yeah, sure. Good. High school, I mean, we're talking about collegiate level here, but I haven't had a high school kid ever go back after a shoulder dislocation in the game. Any other comments there? I've had a big strong lineman dislocate, go back in the game. And I can't remember, I think he was a tackle. And so on one side, because where his arm was on the outside where he dislocated, we switched him to the opposite side so that he didn't have, he could always keep his arm that was dislocated internally and then took him off defense. So I've had one kid that had, I think he had dislocated one time before and he was a senior star player on a team. So it is possible. All right, very good. Rapid fire case number three of NFL linebacker. The first quarter of a road game, one of the teammates tells you or your athletic trainer that he was shaking out the cobwebs last series. He's walking towards the wrong huddle after a big hit. You evaluate the athlete and the symptoms are basically normal and his testing is normal and he's alert to Deshaun's five questions that he showed us in his talk. So what do you think here? Well, I think he's demonstrating some of those no-go, even though his symptom, whatever the symptom score is, if that's the Maddox questionnaires that you're referring to, he's demonstrating some behavior that's concerning for a concussion. And I think the way that you could try to manage that, if it's the first quarter of the game, you could try to hold them out, reassess them at halftime. My guess is there might be some evolution of these symptoms, but just that shaking out the cobwebs and that just kind of hits some of the red flags that would make it very difficult for us to bring someone back into play. Yeah, I think holding out and reassessing on the sideline is really good here. Anything else to add to that, Kurt? No, nothing, I agree. Okay. Juco, offensive lineman, first quarter of an away contest, complains of shortness of breath and chest tightness. He has a history of poorly controlled asthma. You listen to his lungs and he's wheezing a lot. He's unable to improve his symptoms of the rescue inhaler, but the EMT with the bus on the side of the field brings a nebulizer treatment out and he's much improved. So this is a Juco offensive lineman with a resolved asthma attack. What are your thoughts here? No go or no go? No go. Not gonna go back. Tyshawn? Yeah, I think without knowing the full medical history, I think you're opening up yourself to a significant amount of potential problems if anything else happens down the line here. So I agree with Kurt here and no go. Well, you have to, you know, asthma kills people every day of the year. People with a bad asthma attack die and can't be controlled. And so I think that you have to, you know, you look at the risk and the risk is, even if the risk is low, the risk could be death here. So in my mind, when you're factoring into something where there's a certain risk of death, he's already shown that he, you know, the EMT has had to come out and control it. I don't think there's any reason that you should put this individual back in the game. In fact, what you should do is at the end of the game, have somebody figure out where his home situation is and what he's doing and figure out if he can get better control. Then he can play football. All right, very good. Great points. So rapid fire case five, we have a high school women's soccer game. First period, the midfielder has a tonic-clonic seizure. She's postictal and for a few minutes, she has a history of seizures and she's on preventative prophylactic medication. Her parents arrive to the sideline and confirm this history. She's completely normal by halftime. What are your thoughts, go or no go? I'll tell you, since I can't remember what a tonic-clonic seizure is, if you're having a seizure and that's what you have, you're probably not going back in the game, at least if I'm on the sidelines, so. Unless you have a CAT scan to be at halftime, the CAT scan and a neurologist to completely evaluate what's going on, they're not going back in. I'd have to agree with that. I mean, you'd be pushing it. I think the safest thing is obviously to hold an in-game seizure. Other considerations, yeah, Kurt brought up the CT scan and formal evaluation by the neurologist and good communication with their family about the event and maybe updating their medications with their neurologist, so. Finally, case six, this is a Division III football contest. Pre-game, it's hot, it's 83 degrees and sunny. It's about 2.30 p.m. You have the ortho team physician, the primary care sports medicine fellow walking out to the sidelines. They look up at the stands and they see on the visitor's side a visitor that's unconscious on the bleachers. EMS has not yet arrived at the field yet, so. Fan in the stands pre-game, so small college in need of medical care. So what are you gonna do here? I think Kurt and Tijan, how are you gonna approach that situation? I think that always brings up the interesting dilemma of who are the team physicians there for? But obviously, do no harm, we call 911, see how we can provide support and then kind of get a sense of how quickly we can try to at least try to provide some stability to that situation. I think the primary care fellow would be much more helpful than the orthopedic surgeon in this particular instance, but hopeful that this issue could be resoluted quickly with the EMS's arrival, but to get cooler off as best you can and call 911. Well, I don't think you can make, I don't think that's one that you have to go back and say, you know what, this is a medical issue. A person stands, it could be anything. It could be the fact that they could be dehydrated, it could be heat exhaustion, or it could be they could have a low blood sugar, or they could have a high blood sugar. You know, or they could have whatever, it could be anything that's going on. It could have a stroke depending upon the age of the patient. So I really think you have to sit back and do your ABCs and get as much expertise as you can, particularly the primary care person, someone else to come over, but you can't, I don't think you can make an assumption of what it is. It's not like it's one of your athletes or one of your younger people where it's almost entirely gonna be heat related. This may not be, this could be anything. It could be drugs as well. Yeah, it'd be, I mean, that's good, really good points. Just be a reasonable medical doctor, call for an ambulance, call for help, assess the patient, support them any way you can. So these are things that, strange things do come up on sidelines and anything can be really thrown at us. So I think I would like to wrap it up here. I think I'd like to thank Kurt and Tishan for participating and Kurt all the way from France and staying up till 2 a.m. to give your talk and contribute greatly to this discussion. I'd like to thank you both for really sharing all of the knowledge that you have with us from the NFL perspective and from all the years at Vanderbilt from Kurt. Really great, thank you to the AJSM and the AOSSM in a combined effort to put on a webinar like this at this time of year in the fall where we can really highlight some of these important issues for a lot of the docs, physical therapists, athletic trainers that may be on the webinar to really highlight safety aspects on the sidelines. So I really appreciate you Tishan and Kurt for participating, really sorry to miss the tool. I do wish him and his family well during this time. But again, thank you for the panelists and thank you to the AJSM for allowing us to do this. So we'll wrap it up here. Thank you, my pleasure. All right, a big thanks to our panelists and presenters for their work on tonight's webinar and thank you attendees for your participation. If you're interested in CME or would like to view the recording of this webinar, please go to education.sportsmed.org, log in, click My Resources, and then click the course title. You can then complete the evaluation for CME or view the recording which will be available by Friday. This information will be emailed to you in 24 hours. So please don't worry about remembering it all. We thank you again for your participation and have a great rest of your night.

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