We'll get this to noon, but we'll just talk about, we were going to present three cases, some of which have been talked okay already and reviewed. And really we'd appreciate audience participation in this, so questions or comments during this session are much appreciated and encouraged. So I'm going to do the on-field traumatic collapse. So if you just get to the next slide, I'm just going to, so this is my case. So if you go to the next slide and then there's a YouTube video that you could play. I don't know if I have that ability. Back at Honda Center while we were away during the television timeout, a situation on the St. Louis bench and the emergency medics on the ice, the stretcher brought out, both teams collecting themselves at center ice. It was a wild scene on the St. Louis bench as players lifted the bench out of the way in an attempt to make room. John, he just collapsed and we're uncertain as to which player it was at this point. Initially signaled for Anaheim's trainer that there was a problem on the bench and immediately he sent a signal to the two team doctors who are placed, positioned immediately behind the Ducks bench and they were on the scene within about 30 seconds, I would say. At this point in time, we believe the player who is down to be Jay Bollmister. Both clubs gathered at center ice and trying to give as much room as possible, but obviously there's a great deal of concern. I think it's about over. We'll let it play out. So all right, panel, you're that person behind the Anaheim bench. So again, Michael, you made a great point and that is, so the St. Louis Blues are the visiting team here. So real life scenario, I don't know how many of you all remember this. Fortunately, I can tell you there was a happy ending and what have you. And so you're that, so you're at the mercy of the home team. And so for the panel, so what's your thoughts? You know, somebody in a non-traumatic collapse, Nancy, what's your first thought process as you get to that person? I'm going to venture that it wasn't heated. I wanted to give that first clue to you. I will say though, just because it's not a warm weather environment, just because you're not in a warm weather environment, you know, we joke about that, but you cannot exclude because remember, it's more than just the absolute temperature heat. It can be humidity, direct sunlight, no wind moving, time of day, and then obviously your inherent risk of your athlete. But I think this non-traumatic, it happened in the bench area. So again, as you're just assessing your differential. So in that scenario, already sudden cardiac arrest has risen to the top. So put the pads on, immediate CPR. Put the pads on, immediate CPR. In this scenario, right, you're on ice. You know, your emergency medical crew may have been on the other side and you're coming across the ice. So I think you have to know your environment and you have to know where your EMS, where your emergency medical team is. But there should be an AED, maybe that's it, sitting over there in the corner, readily accessible and know how to use it. And then I think the other thing that we all have to do and rehearse is you've got jersey on, you've got pads on, you've got equipment on, and you need to get to the chest. The AED won't work through that jersey. So those are the things that you want to have rehearsed before you get into this situation. So Lee, since you most painfully make me rehearse this on a regular basis. So I think, Nancy, you bring up a great point. So Lee, take us through a little bit, our rehearsal, what's that look like? Yeah, you know, we rehearse multiple times a year. Like the Dolphins, we bring in a third party just to kind of audit the process and, you know, push us to get better each year. But we really, really, the NFL provides us a list of scenarios that we have to run through and we make sure we hit on all those, everything from cardiac arrest to heat to cervical spine injuries. But it's an orchestrated approach with all of our medical staff, our team physicians, our area management physicians, our unaffiliated neurotrauma specialists, our paramedics. I mean, it turns into a group of about 50 people, you know, all on board, all practicing the same way so that when we get in a situation like this, you hopefully press the autopilot button and it gets taken care of. Well, you know, the person that saved this guy, you trained, right? Yeah, I think we did, right? Yeah, for sure. But I think, you know, one of the first things for this video that we would do is, you know, give the all come sign and, you know, be able to activate the plan. And we rehearse those signs and everyone knows what they mean and, you know, all come means everybody trained in the emergency action plan get on site and ultimately fall back into your roles, whether it's, you know, gathering the medical equipment or, you know, controlling the scene or identifying the paramedics, getting the cart. So everyone kind of falls back into their role. But none of that happens without, you know, planning and, you know, each year, multiple times a year. So Kevin, you know, at the NCAA level, how much has evolved in terms of rehearsal and, you know, I mean, we talked about the planning, but the resources available and the emphasis on rehearsing such emergency action plan. Yeah. And, you know, I think that we really lean on you guys in the NFL to learn from you because you guys have streamlined it so well and commend Dr. Sills and everyone who's been involved with that process. I mean, I think you guys just had a webinar recently that about the Hamlin incident. We all watched as well, so we can learn from it. You know, at our level, you know, we're probably not far behind in the sense that, you know, we do do the emergency action plan, the practice. We go through that. We don't have a third party that we do it ourselves. The problem is we have 15, 16 teams in 10 different venues, so you really got to try to do that at each one, obviously. And so that's more challenging, but each team should kind of run through that. But you know, I think at the lower levels that don't have kind of the financial support that maybe some of the upper division one teams have, I got to imagine that that amount of practice and preparation is probably not feasible. And certainly, hopefully over time, we all learn to help, you know, help the other divisions and kind of move up and so that we can learn just like we're learning from the NFL as we follow what you guys do. And then, Michael, you know, how applicable is all this to a high school? I mean, what's our goals here? I think a lot of it is exactly the same, right? You know where you are. In this particular case with hockey, you have to consider going on the ice without skates, you have to be in the bench, or if someone goes down on a penalty box. Those are very tricky scenarios that football doesn't have to deal with. However, in football, you're going to have to deal with rain. You need to establish who is going to be at the head. You know, these are one of the things you train for in the EAP. Who's at the head? How are we moving them? Who are we calling? Do we have... Is EMS there? Do we have to call them? And so the protocol is essentially the same. It's the details of how you get the, recognize that there's a problem, start treatment and determine disposition, whether it's, you know, transport. So in this case, it seems like they moved him pretty quickly. One of our arguments that will go over our EAP is when do you get them off the field? And for right now, our main point is to start CPR and continue it and get the AED and try and get ROSC or return of circulation as soon as possible, and then worry about getting out of the limelight and getting out of transport. But in this case, they may just not have had any room to do anything and had to move them back. So high school should be the same. You should have, you know, spine board, AED, and access to EMS. The one consideration for high school that what I'd add is, you know, at our level, as I mentioned, we have 50 people on the field, we have a mini ER basically within, you know, within 10 to 15 yards. I think the talking point about high school should be, you know, once the player leaves in an ambulance, does someone go with them in regards to making sure the equipment comes off safely? I mean, I know, you know, our setting, we 10 times out of 10 send an athletic trainer or send a physician with the player who's trained in, you know, successfully removing the helmet and shoulder pads, making sure there's no secondary injury or unnecessary cervical spine motion. So that'd be one thing on the high school side to consider is what happens once that player leaves the field. Yeah, I think what we can all do is advocate, you know, different, less resources don't mean less plan. So I think any kind of scenario, you got to have a plan, but everybody needs to think about that plan. But I think the most impressive part of this video when you listen to it is the physicians were there in 30 seconds and the announcers are noticing this, you know, and so that's clearly, you know, so Kenton Feibel was one of my fellows. So you know, this is, you don't do 30 seconds if you don't think about it ahead of time. So we'll move on. Well, unless there's questions, comments in the group, thoughts, especially there's a view that... Just a quick plug or comment, I don't think. We had a cardiac arrest at the University of Pittsburgh this year, it didn't get on TV because it was our assistant basketball coach and it was in his office. And had we not trained our staff in CPR, he would not have survived. It ended up being the assistant women's basketball coach and one of our donor gifts folks that saved his life. Ironically, there was a concert in the venue that day, it was mega death, you can't make this up. And they came and assisted, but the point being is, is I just want to put on a plug, we're talking a lot about like game day operations, but I would encourage everyone to look at your overall organization and think about making sure that your staff is trained because statistically speaking, who's at highest risk? It's our assistant basketball coaches, right? And that's what happened. So just a plug for that. Perfect. So I've got the next case too. So this is, I do not have a video, this is just one of my worst nightmares. So I'll share this with the panel and the audience. One of my pet, you know, one of the things I just don't like is I'm standing watching the game, observing the field and I get a tap on the shoulder and so-and-so's feeling shorter breath on the bench. So I'll start with Michael, you get to go first. How much do you like that any more than I do? Because what's your differential diagnosis? So you're walking back to the bench and quote unquote, he's feeling shorter breath. You know, the, the differentials, everything from, from asthma to allergy to lung tissue injury, to, to rib injury, to, you know, pulmonary embolism. So you have something that's, can be relatively benign and treated easily to things that can be life threatening very quickly and require transport to hospital. And these are guys who are exercising outdoors in the heat and, and they have other reasons sometimes to actually be short of breath. So it's challenging to determine in 30 seconds how severe the case can be. All right. So Nancy, what, what's your next step? You go back there, take me through what would be your, your initial surveillance. And by the way, does anybody else have to deal with this too? I think A, B, C, D, right. And maybe we reverse the order. Obviously that's fresh on people's mind, but you know, you're assessing their airway breathing, you're getting an assessment of the situation, getting a history. What was the pre, what were the preceding events? Is this a traumatic injury that, that just preceded and now the players come off the field? So I think that's, that's where you start and you're going to get a set of vital signs and examine head and chest, neck, anything that could be involved. Lee, what do you think? Yeah, I'm usually the one tapping on the shoulder, but I think the athletic trainers have unique perspective because we know the athletes and we, we kind of, we know them the other six days a week outside of game day and we kind of know when someone's a little off for who struggles in the heat or who has asthma. So I think we can be a resource to the physicians in the sense that this, this is just not right. There's something going on here. So that's kind of how I see our role on the field. Yeah, I think that's exactly right. I mean, I think my personal experience is it's really hard to sort much of this out on the sideline. And so a little bit to that, the athletic trainer and the people that know them and oftentimes you as a team physician know them, but you know, I think this is one that if it really seems like that's a complaint, I don't think this is in my book, something you evaluate on the bench or even in the blue tent. First of all, my ears are not good enough with background noise nowadays to listen to people. And the other thing, you know, it's my view of this is you take them to a place you can evaluate them, if you have that available to you, and you take them to a place where you can get a pulse ox, you can get true vital signs, you can get the pads off, you can listen to them and sort this out. I do think this whole trauma or not trauma, which is a little bit of a joke, because if they're playing football, the odds of them getting hit was 120%, so you kind of go, okay, that's in your differential too. I really want to palpate their chest and what have you. So I think there is this, the reason why I want to bring this up, I think it's a little, our emphasis is don't miss time, but I think if in some scenarios, and this is one of the ones why I don't like it, because I think don't shortcut your evaluation, and I don't think you can probably appropriately do this on the bench or even in the blue tent in our setting. Thoughts on those comments? I think, obviously, orthopedic surgery, I'm going to pass off to my primary care colleagues, but certainly I would rule out the bad things first, so tension pneumothorax. I've seen a player get a rib fracture in the first quarter, play through it, and end up presenting with a pneumothorax in the second quarter over time. So things like that can progress, even though they didn't have trauma right then, all of a sudden it turns into an emergent situation. I've seen pulmonary edema following high-velocity IV in halftime, and so weird things like that should always be in your differential, but I would agree, get them into a quiet space, you can really evaluate. Another thing is have a good method, if you have any concern, we've sent players out for a CT scan, lung CT in the first quarter, and got them back by halftime with a normal lung CT, and then felt a lot better about things to play them in the second half. So have a method like that, potentially available if possible. Perfect, I mean, we've talked a lot about, you know, maybe having more availability for us, point-of-care ultrasound, right now we don't really have that as a routine, as a requirement, but we work with our BTMLs, our visiting team medical liaisons, they're always kind of going, well, if I had an ultrasound, we'd just kind of slap it on and take a look, and I'm thinking maybe we should have, you have an ultrasound, but, all right, Michael, you got the last scenario? Right, so my scenario is, which I'd like to be informal with you guys, if we can, instead of doing slides, is just talk about very similar case, right? Some of these medical cases come off a little bit on the vague side, and the severity can be benign to life-threatening. So, I'll start with Dr. Kinderknecht, so if a player comes off the sideline, your athletic trainer comes to you and says, he's a little dizzy and has some abdominal pain, you know, how are you evaluating that on the bench? I think in arts, in the sport of football, I think you assume, and this is to Kevin's point, that it's trauma until proven otherwise, and so I think I have that mindset, is, okay, did they get abdominal trauma, is it significant? And again, kind of my same comments, I don't think we shortcut our evaluation, and so, and, we had one this year, it was all over TV, but where we had an athlete basically kind of get kicked in the stomach, making a tackle, and it was kind of, it was scary on the field, just because he was in so much distress, you know, and just the amount of discomfort, he really tried to sit up, couldn't sit up, and at that point, you know, we're going back to, so then I say, we gotta go back to the locker room and evaluate him, and then the other consideration, we're a weight team, so, you know, how much am I gonna live with not knowing what's going on in this guy's abdomen with that, and getting on a plane and flying home, and so, you know, Kevin, your point, we have the VTML again, and so it was like, let's just get a CT of his abdomen, so that was a, that happened in the playoffs this year for us, but I think, you know, I think my thoughts, Michael, there is anybody in the game of football, and I would say that transfers over to any collision sport would be, is this a, is it a trauma-induced event? No, Nancy, so piggybacking off of what he said, so if you had an athlete coming off with dizziness and abdominal pain, under what circumstances would you consider keeping them on the field, right? Because he mentioned transport, or, I mean, you know, to transfer every single person that has abdominal pain is, I think, a hard thing for a physician to do. What would make you feel a little bit more calm and safe that they could return to play, or conversely, what would you see that would make you more concerned? Obviously, hemodynamics, I mean, you know, we're thinking about intra-abdominal injuries, thinking about traumatic injuries, the spleen being the big one, you know, so we don't even have any information about the location of the pain, and they could be presenting with shoulder pain, it may be referred curve sign, so it doesn't necessarily point to the actual location, so I think, you know, your exam, your set of vital signs, and your index of suspicion would determine, so again, your first evaluation may be field side in the locker room, vital signs may be stable, exam may be benign, and then it's serial examinations. I definitely agree with the serial examination, so Lee, let me give you some statistics here, so for a splenic laceration, they have abdominal tenderness only about 50% of the time, the research says that if that's your consideration, you really shouldn't be pushing on their belly, because you could make it worse, tachycardia is a soft sign, and hypotension is only in 20 or 30%, so how can you help the physician, since you know the athlete better, kind of gear, is this a guy that needs to be transported or not? Yeah, it's a good question, and it kind of goes back to what I had said earlier, you know, we tend to have pretty good relationship with our players, you know, we know what's going on in their life, we know what's going on in their family life, we know the context of what's going on with them and the team, just for us, it's a matter of looking at the player and seeing how they're acting, you know, are they acting a little funny, are they out of character, are they off a little bit, and being able to give that information to our physicians is helpful. When, you know, Kevin, when you evaluate a rib injury, how do you involve? The primary care doctor to assess for any more internal organ damage? Yeah, we end up seeing those together, we just saw a guy two days ago, we thought maybe he had an SC injury, so I went and evaluated the SC, and I let primary care listen to the lungs and, you know, go through what they needed to go through. We had a splenic injury this year, low grade one that we diagnosed with an ultrasound in the locker rooms, we have an emergency med trained personnel at home games, which is really beneficial, because they can look at, they're kind of better trained in looking at those kind of things than we are, and so in that case, he saw fluid level, whatever they look for, and then we sent him down, the CT scan confirmed it, so, you know, I typically will do the rib exam and those kind of things, and look for anything that jumps out to me, but if there's any question, abdominal, shortness of breath, I'm gonna ask their opinion, and usually do an evaluation together. So overall, intra-abdominal trauma is a very, very rare problem, and splenic is about half of the case, which would be more left-sided, and if it wasn't left-sided, you should definitely think more about liver or kidney, but one of the points is that, you heard that it requires everybody to review this, you know, the athletic trainer that knows the athlete very well, the orthopedic surgeon who can review the ribs, because recent rib trauma or recent trauma is one of the biggest risk factors, it may not be that one hit that you just took, it may have been one hit that they took that did a partial injury, and then another one that took it further, or maybe they were sick this week, and you know, you didn't pick up the mono, which obviously can happen, and then they're at risk, so this is a very rare event, and when things like this happen, I can tell you I'm uncomfortable, and I think having everyone around to think about it, and especially if you have someone like a VTML or an emergency physician there can also be helpful, so use your resources, and really the serial evaluations, right, because our talent is supposed to be, our challenge is how do we keep them on the field safely, and simply sending everyone with a tummy ache to the ED for a CT scan seems, can be a difficult choice to make, so you wanna try and return them if they can play. I don't know if anyone has any questions in the audience. Yeah, I mean, I think with the potential trauma being involved, if they're showing distress, and to me distress is significant pain, as little as, you know, significant pain, it's really hard for me not to think that that person isn't gonna go to the emergency room and get evaluated, you know, and so, but, and yeah, you're gonna send a ton more people that didn't need to go than needed to go, but, you know, it's like we're talking about, you know, they're playing a collision sport, and they're coming off complaining of abdominal pain, I don't think, I think they have a virus or something, so, so I think, you know, and then, I mean, this case I just had in January was, you know, by the time he was going to the emergency room, I kind of felt like he probably didn't need to go to the emergency room, but I wasn't, and then I kind of, yeah, and then at that point, it was like already set in place and what have you, so, so, yeah, but when, but it's still to, I mean, he was in so much distress, and he actually, to exam, he had very significant hematoma in his rectus abdominis on the right side, just off his umbilicus, and his vital signs were fine, and I told Pat Smith this story, so, so Pat taught me at Missouri, we worked together, and first thing you do is, as soon as you know they're okay, you have them call their parents, so I asked, I asked Jason, is your mom here? He said, no, I said, you should call her, and so we called her from the locker room, so that's the other pro. But to your point, Doc, he was out of character, I mean, we know that player, and he wasn't acting right, you know, he was out of character, he couldn't sit up. Like I say, you know, I mean, when we tried to sit him up in the field, and he just laid back down, and I'm like, how many people do that, so. I think the other lesson is that you may be seeing him now, but you don't know what happened a quarter ago, you know, five plays before, you didn't see that part, and then concomitant injuries, so you may think it was a rib injury, but the structures that are beneath, be it a spleen, be it a kidney, and then the collaborative approach, the collaborative approach. And I recognize the value of point of care ultrasound, but I think in those instances, trust your judgment, trust your skill set, and I don't think you'd be returning that player back to play if you didn't see free fluid, so use this. I think that's, I mean, the thing we deal with, the scenarios that we deal with, I mean, if you're covering a high school game, you don't know who you're sending this kid home to. I think in that setting, I think in the setting where you're on the road, you're gonna get an airplane, and do you really want somebody to not do well on the airplane? So there's some other factors that, you know, being closer to 100% right is better than a sometimes 92% right. Hey, Jim, a quick question. You brought up the idea of the serial exams, but any pearls or thoughts as to what you do if someone may not be bad enough to go to the emergency room, but if they're a college athlete, do you send them back to their dorm room? Who checks in with them? Do you phone call with them, see them the next morning versus someone checking in on them that night? Any thoughts on or comments on how you do the serial follow-ups for someone that you may be seeing something evolve? Yeah, I think, you know, James, you articulated what needs to be done, because I think what you've heard from the panel with a lot of this stuff, close trauma to the chest, close trauma to the abdomen, they may look okay, and then six hours later, they're not so okay, so I think, I think, and that's a bit what I guess, you know, talking about where are you sending them home to, what kind of resources, but I do think you gotta be very comfortable if you're not imaging them that you have in place very tight surveillance and comfortable with where that surveillance is gonna be. So in some settings, it's really easy, in some settings, it's clearly not. This generation of athlete loves to FaceTime, so it's never difficult to get them, that's for sure. What did we say earlier about the hardest working group? Our athletic training staff, so that's where someone is assigned and someone's making that dorm call, that house call. Great, with that, I wanna thank the panel for a great session, it was wonderful, and I think what we come back at, you gotta hear me again, at 1.30, yeah, 1.30. So, and then lunch, and then there is a Legally Mined, proper use of legal, no, am I on the right page? Yeah, Legally Mined is having a symposium if you'd like to join.

on-field injuries

emergency plan

AED

shortness of breath

abdominal pain

collaborative approach

legal considerations