Good evening. Thank you for joining us for the AOSSM Fellows webinar, Transition to Practice as a Future Teen Physician, Perils for Success and Medical-Legal Implications, with faculty Drs. Eric McCarty, Matthew Provencher, and Armando Vidal. Dr. McCarty is Chief of Sports Medicine and Shoulder Surgery at UCHealth in Denver, Colorado, and Associate Professor of Orthopedics and Fellowship Director at the University of Colorado. Dr. Provencher is Shoulder, Knee, and Sports Medicine Surgeon and Fellowship Director at the Steadman Clinic in Vail, Colorado. He is Principal Investigator of Steadman-Philippon Research Institute and Chair of Vail Health IRB. Dr. Vidal is Shoulder, Knee, and Sports Medicine Surgeon at the Steadman Clinic in Vail and Clinical Associate Professor at the University of Colorado. Thank you to OSER for their support of this webinar. To submit a question on the GoToWebinar panel on your screen, click the Questions drop-down arrow on the right-hand side of the panel. This slide shows you where you input your question and click Send. I will now turn this over to Dr. Provencher to begin. Meredith, thank you very much, and I want to thank you for helping us set up an incredible Fellows education. We know these are not easy times to do education, but in many ways, we may be getting quite a bit out of this. So I want to thank you all for your time tonight, and Meredith, thank you all and to AOSSM for setting this up. And lastly, to OSER again, thank you for your generous support of these programs. These can't happen without support. So this is a topic that is near and dear to my panel's heart and myself. This is something why we went into sports medicine. This is AOSSM. We like to take care of athletes, but it's athletes of all ages, and it's getting people back to what they love to do, and that's why we're in this specialty. These are my disclosures. They're also available online. And with that, I'd like to introduce my distinguished panel that Meredith already ran over, Dr. Eric Hardy, Dr. Amado-Badal. They really need no introduction, and I'm so happy that they were able to join us tonight to provide their expertise. We're going to go through tonight a format of some pearls for being a team physician. You are all on the precipice of graduating here very soon. You're going to be asked to be leaders in your community, leaders in the schools from an athletic and a medical standpoint, and leaders for professional college and other departments. And it's going to happen before you know it. So these are some of the pearls that we've put together. I certainly did not come up with these, but I think over the time of just diffusion, learning from some of the greats, and going back to people like Jack Houston, Jimmy Andrews, and so many others that have taught us so much on the sidelines. I went to the United States Naval Academy, and I knew nothing about medicine until I got injured, and a guy named Eddie McDevitt, a former Hall of Famer in the AOSSM, took me under his wing and got my elbow better so I could head back rowing. I didn't know anything about medicine, didn't know anything about orthopedics, but I will never forget Eddie McDevitt and how he took care of me as a rower, as an athlete, as a student athlete, and then helped continue to mentor me along the way. And there's just been so many great ones, including just recently the late John Fagan, among so many others that are in our society. So what is the role of the team physician? It's becoming increasingly complex, and depending on what level you are, it can be complex, but the reality is that anytime something is complex, what I would ask you to do is go back to what is the lowest common denominator, and that is taking best possible care of the athlete, the athlete of all ages. But you're going to have to be saddled with administrative responsibilities, you have to be a leader on the medical team, and player education and medical care are paramount. The responsibilities of the team physician to the players, to the parents, to the team, to the coaches, it's not just to the players, but primarily anytime you're in a difficult situation, the player always comes first. Basics of the team physician, you have to be available, compassionate, empathetic, you have to be realistic, you have to tell the athlete that maybe this may not work for you, this may not be able to come back from this, and these are tough conversations, not the one you want to have to have right off the bat, but sometimes you have to do this. But communication is key, and you have to set up that culture of trust that allows you to communicate, and the other thing is a lot of us have played these sports or done sports in the past, even if we know nothing about the game, I would implore you to learn a lot about the game that you're covering or taking the athletes of, because they'll respect you a heck of a lot more for it. So what are the minimum requirements, and you can get this through our combined societies until the AOSSM has been in the forefront, the AOSSM, as you know, has a team physician committee, it's a fully recognized committee, and the consensus statement, which was revised in 2013, these are the minimum requirements, you have to be an MD or DO with unrestricted license, have an understanding of musculoskeletal injuries, medical conditions, and sports, a knowledge of some level of emergency care and sporting events, and then minimum trained in CPR, and I would tell you probably ACLS is probably a good thing to have as well, because guess what, you're the doctor to all of them, although orthopedic surgeons, sports medicine professionals, guess what, heart and other emergencies can happen, and I think it's incumbent upon it, so I would add ACLS to that list and stay up on it, and I keep up on mine just for that reason. You are responsible for the health and welfare of the athletes, they're number one, you direct the medical care and you organize the medical team, depends a little bit on your team and team structure, and we'll touch on this in a little bit, but the chain of command for injury and illness management is very important, so that when an emergency happens, you've practiced it, you know what to do, and you know how to care for that athlete and get them immediate care. We did tons of backboard exercises, tons of emergency procedures, tons of drills, why? Because it was all about education of our team, I've learned something every time that we could do better, that we'd be able to put in a better place to be more efficient, to be safer for the athletes, to get the AED locations better for example, there's so many lessons learned, and when you drill and practice, it's so important in what you learn, and it's going to be better for the athletes. I think that another key point is making final decisions on return to play, a lot of these are musculoskeletal injuries, they're not always, sometimes it's concussion, sometimes it's other things, sometimes it's illness, sometimes it's sickness, sometimes it's COVID, and now you're going to be expected to make some return to play decisions, so it's becoming increasingly complex. Good news is, you can enlist help of people around you, and you have a lot of excellent assistance as we'll talk about. It's important you provide ongoing medical care just beyond game day coverage, you just don't show up and stand on the sideline, or stand at the 30 yard line, or stand on the sideline of the soccer game, it's much more than that, that's maybe the culmination of all your efforts, and the buzz of the crowd, and everything else going on, but it's really so much more than that. It helps guide injury prevention and wellness program, you have to be in charge of that, you have to recognize other issues that affect athletic performance, you have to be the champion of documentation medical record keeping, it's super important, just like in our clinics, we have to do really good medical records on our athletes. I walked around with a dictaphone for all the teams I took care of, and I had it in my pocket, and there was really no such thing as just a quote-unquote sideline medical visit with any of my players, I would always document it. Mr. Jones came up to me and had a sore throat, said he did this, we talked about this, etc., plan was this, even if it's a two or three sentence note, it's super important to document it well. You have to be involved in development, rehearsal, emergency action plan, we touched on this a little bit, but the EAP is super important, and people are going to be looking at you to make sure that this is done correctly, but you have a lot of resources to help you with this. And then involved in other aspects of sideline and event preparedness, supplies, equipment, what's the wet bulb temperature, what's the flag condition for humanity, etc. Medical leadership I think is really important, you have to build the team and really operationalize the day-to-day, you just can't show up on the weekends, if you want to be involved in the medical team, you have to be involved in the medical team, you have to empower your people, because there are a lot of people that are doing this full-time, we're not doing it full-time for the most part, but you have to set the tone, empower your people, and they're really good people. The athletic trainers, the physical therapists, strength and conditioning, nutritionists, depends on what level of a team, but at some level it's a minimum of an athletic trainer that's going to be involved on a near full-time or significant part-time basis. When I was with the Patriots, you had to be excellent at what you do, do your job, and we use a lot of communication such as here to really help set up our organization and really lead from the front. Team-oriented mindset is paramount, it's all about your people, I think you want to understand the team prior and making sure that you understand this, but building a team together, and it's really important now, if you're coming in and starting to work with a new high school or work with a new college or you're bringing someone in, you're going to learn a lot about that as you come in and maybe brought up through the ranks and up through an assistant team physician to the team physician, and I think that's very important as you go through this. You never want to tell people how to do, but give them some guidance and let their ingenuity take over, is a very good famous quote here. So these are some lessons from my experience, it's important to be decisive, but be persuasive, embrace change, be the driving force if you need to. There are many teams that are doing just well, but there are some where the medical care might need to get a little shot of adrenaline, for example, and it's just not up to what some standards might be, so you might have to create a little bit of sense of urgency and now, if they don't have an emergency action plan, for example, coming up this summer, if they don't look at humanity now. You may get this few and far between because the state athletic conferences and high schools have a lot to do with this now, there's a lot of regulations on this now, but sometimes you'd be surprised, and it's really good to take a deeper dive into what the programs are, what the vision are, and if you need to be the inspiring and motivational person to do that, you have to create the vision for the team. Don't stop learning, you have to really know your job, know the sport, know your job, hold your team accountable, but learn how to also let go of those down the road who don't share the vision, and sometimes there may be those people, it's just like in any organization, you're going to have to make some tough decisions at times, but that decision may not come to you, but a consensus in terms of, again, what is in the best interest of the player, and if there's someone on the medical team that's not always there, not always doing the right thing, then it's an easy decision to make. To learn from other great leaders, certainly these are some of my heroes in the military and around, and then with that, we're going to learn how to do it right in 2020. Eric McCarty, do you mind taking us through this? Eric is no stranger to the football field, having played himself and now on the sidelines. It's sometimes hard to reverse that role, but I think it's one he's very comfortable in at this point. Eric. Matt, hey, thanks. Great intro over the past 10 minutes, and what you'll hear in the next 10 to 15 minutes from me is some repetition, but also some other little nuggets that may be helpful for you, and as the fellows out there, I know that most of you are interested in being a team physician, or you wouldn't have done a sports medicine fellowship. Now, that's about 80% of those that do a sports medicine fellowship are interested in the team physician aspect, and that's a very important part of what we teach our fellows, and you're learning from some great people today. Matt, you used to be the team physician for the Seals, and then the Patriots, and has a great depth of experience, as you just heard, and then Dr. Vidal worked with me for about 15 years and was a team physician for the Colorado athletic teams, and then the Denver Nuggets as the head team physician. So we've all got a wide spread and breadth and depth of experience. So in preparation, you got to get ready for the season, and that includes the medical team, all the policies and procedures that go with it, and you need to have practice. Practice makes perfect, and repetition is the key to learning, and the great John Wooden said that long ago, you want to have repetition, and you want to do this all the time and get ready because you want the first time, you don't want the first time to have something bad happen that you didn't practice, you want to do it before it happens. So going and getting ready for the game, there's some logistics that we'll talk about. Next slide, Matt. So team physicians, you know, we're the top in the chain of the command of the sports medicine team, and the NCAA has mandated that there has to be independent judgment, and that's really true whatever level that you're at. You've got to be an independent decision maker. You can't be making decisions that are based on what the coach wants you to do, what the management, the athletic director, the agent, the family. You have to be independent of that, and you want to do what's best for the player. So we medically manage the players, and that's not just orthopedics, that's going to include other aspects. If you're a high school team physician, you're going to be taking care of everything. In college, we're fortunate enough that we do have a family practice and internal medicine and other people that we can call upon, and it's us, it's up to us to make the decision on return to play. That's not the strength coach, it's not the coach. Now, communication with them is really good, and you need to have that, but it's up to us to have that ultimate decision on who returns and how they return to play. The coach's responsibility is really to take care of the athlete, and that's who we're doing this for, right? So the medical team varies with the level of competition. Now over on the left, you have the one physician, and that's going to be probably the high school. There are some colleges that have just one physician. As you go to the right, that's going to be at an institution like the University of Colorado where we have multiple physicians, and you have consultants and sub-specialists. I'll guarantee you that when Dr. Burbenshire was in New England, he had all types and many of the different types of sub-specialists and consultants to help out. I know Dr. Badal did with the Nuggets, and I do with the Carl Avalanche. So it really varies with the level of competition and somewhere it's in between, but for many of you just going out, you're going to be the guy. So recognize that the medical team shines or fails together. You don't try to be a hero. Don't try to throw anyone underneath the bus. We're all in it together. So any decisions that are good, we all made a good decision. Anything that seems to be bad, we all made that decision to be together. So nobody looks like they're all standing out on one side or the other. We're in this together. Create or be part of the medical team. Remember, you can't do it by yourself. You know, we're all smart docs, but realistically, you know, we can't do it all. I don't care what board scores you get. I don't care the in-training exam scores or anything like that. You can't do it yourself. You need other people to help out. And that's one of the things I love working with Dr. Badal. You know, we would often be on the football sidelines together, and it's great just to have somebody else to bounce off things to and talk about. Even if it's another orthopedic surgeon, you're in this together. So and create that list of consultants, because you have to have those to take care of the team. And then, very important, talk to them ahead of time. What are their expectations? You know, what do you expect of the ophthalmologist? What do you expect of the internal medicine doc? Just make sure they understand what the expectations are of them. So that medical team, again, can be really quite big, and this is just an example with an orthopedic and typically a primary care physician. And I want to tell you, get a good primary care physician on your team. Dr. Podar and myself, as you can see on that slide above, we've worked together for the past 17 years at the University of Colorado, and I guarantee it's great having a team. And none of us think we're better than another. We try to make decisions together and with the athletic trainer, and it really makes everybody's life much better. We work together, and then we consult the subspecialists as we need to. I don't do foot and ankle surgery anymore. I've got a great foot and ankle doc, hand doc, and so on and so on. So create that medical team, no matter what level that you are. Even if you're in a small town, you might have some that you can't take care of. So find out the people that can. And then our role as a team physician, you've got to be a great communicator. You've got to talk to your athlete and with your athlete. You've got to talk with your athletic trainer. You've got to have great relationships, and that's really important. Matt alluded to that earlier. Get to know your athletic trainers. They're the ones on the front line, and they're the ones that are seeing these athletes, and they know the athletes the best. So get to know them, and you have great communication, because they can fill you in on different nuances of each player. You want to get to know the coaches, and they want to get to know you, too. You don't want to just show up on the sideline and not know who they are, and they not know who you are. It's really important. And get to know the athletes. The athletes are out there, and again, don't be – the time that you're out there, they don't want the first time to see is when they get hurt. They want to see that you've been out there to a game. Maybe you've been on the plane, on the bus ride with them. They see you on the sidelines. Maybe it's at a practice. Get to know the athletes. Get familiar with them. And then get to know the families and the agents. So it's really important that you develop those relationships. It makes it easier when the injury does happen or you have to make some hard decisions. And then know what your resources are and take advantage of those, and be very familiar and be present and available, because that ultimately is what you want to be. You want to be available for the athletes and the teams, and you want to be present. And that doesn't happen if you're sitting in your office or in the OR. If you want to be a team position, you've got to be out there. All right. Now we're just going to go through some slides, talk about some of the things that are very important, preparing for the football season, and that's coming up. It's going to happen some way or another. We don't know what it looks like this year, but preseason physicals, every level of competition, high school, college, pro, the primary objectives are you want to screen for conditions that may be life-threatening or disabling. You want to make sure that they don't have some issue that they may be threatened by their life. So that's number one. And then you want to screen for conditions that may predispose them to further illness or injury. And then there are some administration requirements. The preseason physicals will take place at each level. In high school, it's very important that you look at all the different protocols and policies, and you want to do this at every level that you're at. You want to have a conversation with the high school ATC and athletic director prior to the school year, and put it down in writing. Most of you going out into practice, it probably will be high school that you're taking care of. First thing you do, you get there, you want to meet with the athletic trainer, you want to meet with the athletic director, and also want to meet with the football coach. Get familiar with them, but also find out what policies there are. There may not be any. Now, when you get to college, there are policies, and if they're not, and you're in a smaller division school, then there should be, and we're happy to help you out with different policies that we've had at the University of Denver or University of Colorado, but review and update these written policies and discuss with the ATCs. Every year, it's a good thing to do. Then when you get to the pros, next slide, Matt, when you get to the pros, it gets even more involved, a thicker handbook, and then you want to talk about this with your head athletic trainer, and possibly the management, so that everybody's on the same page, and with the other docs that you work with. Next slide, Matt. To mention this, but you can't do this enough. You want to be ready for anything that happens on the field. Be prepared for the various scenarios of the downed athlete. You want to have your docs that are going to be at the games, your ATCs, and then you want to have your EMTs, too. We do this every year, and we do it for every sport. We do it for football. We do it for basketball. We do it for hockey, and you want to know how to do it, and this doesn't get old. You want to know how to take that player off the ice, or off the field, and going through those various scenarios. Again, you've got to practice. Repetition is key, and then preparing for the game. There's a lot of logistics that you have. There's a timeline of when things occur. You want to know who the support personnel are. What's your emergency action plan? Matt talked about it earlier. You want to know what the emergency action plan is. What's the role of the EMTs, and what's the chain of command? Next slide. The emergency action plan, that is your blueprint for handling emergencies, so you want to go through each part of it. What's the implementation of it? Who are the personnel involved? Again, if it's a high school, it's going to be pretty small, but you've still got to have an action plan. What equipment is available? How does the communication go back and forth? If it's a big stadium, it's going to be a lot different than if it's a smaller high school stadium. What's the transportation? Where do people go? Where is the venue located? What's the nearest hospital? Where are the local emergency care facilities? What can they handle? You might be playing in a small college, but they don't have the ability to handle spine trauma. What's the next plan after that? You want to know how to handle the documentation, very important, as Matt mentioned, and then a timeout ahead of the game is real important. You want to talk about all these things with the EMS and maybe the opposing doc that may be there. You want to review this and constantly improve upon this. Next slide. So, again, understand what the equipment is. You should understand the equipment that you have at each venue, where it is, readily accessible. You've got to have the AED. Know where that is ahead of the game. You're going to a high school game, know where the AED at the very beginning, know where it is at the very beginning of the game, make sure everything is good operating condition. Know where oxygen is and if you have the ability for advanced airways. These are three of the necessities that you should have available for you if you're taking care of a sport that may have issues that go along with it. Next slide. This is just an example of knowing where your personnel and equipment is. If you look into the upper left-hand corner, that's where our ambulance is. So, we want the other team docs to know. We want the other trainers to know. The EMT, we have one on each sideline. We locate where the MDs are and then in the blue is where the main ortho and the main primary care. So, we have docs spread out. We know where the EMTs are. Know where your personnel and where your equipment is. And communication. You want to have great communication. Make sure you get access to telephone. You want to know what the testing of the equipment is and you want to know how to transport. So, have communication. You don't want to be like these poor chaps here that did not have good communication. So, always have good communication in everything that you're doing. Next slide. Again, before the game, this is pretty typical. We're at the University of Michigan. We're talking with their team docs. What are the various aspects? Where are the EMTs? Where's x-ray? Where's the ambulance? What's the protocol? Do you bring on the gator onto the field? Do you bring on the ambulance? We want to know all those things. So, having that time out ahead at the very beginning of the game is essential. In the NFL, it's mandatory. It just became mandatory in the Pac-12 last year. And I think it's just – and we've always been talking to the team docs. Now it gets more extensive with the trainers and the EMTs. I think having that ahead of time is terrific. If you're at a high school, simple. You and the athletic trainer go over to the EMTs. You talk to them. You talk through things. It's like – and then lastly, you've got to be aware of what's happening in the game. We're at Michigan. We're looking at a player on the other side. Know where you are. Situational awareness is key. That's our athletic trainer with that really frightened look on his face. We're looking at a player, and all of a sudden, boom, he gets waylaid. And I'm just down underneath looking at the guy's ankle. Be aware of where you are. Understand what's happening because you never know. Never know where you are or what's happening. Something bad can happen to you. Matt, I think that's the end of my slides. Eric, that was excellent. So please, think about your questions. You can put them into the slide, go to a webinar on the right side, and we're going to have some time at the end. We also have some good cases we're going to do at the end. Armando, quick question for you. What was your preseason like for the basketball, for the Nuggets, and what was your every pregame? Preseason in the NBA was unique because those guys would come in and out of towns and the teams are small. So like football, for instance, you'd have 60 players on a pro team, a hundred players on a college team. You can mandate them to all be there. We'd have 17 guys on a roster and they would come in and out whenever they would want. So we would just have to make ourselves available. You'd get a call that so-and-so is a $30 million a year athlete is in Denver for two days. You just have to make it happen. So going back to your first bullet here, you gotta make yourself available for these athletes. So we would do their physical, the MBA, because of the risk of cardiac issues would mandate a stress echo on every athlete every year. And we didn't feel that that was necessarily necessary, but it was mandated. So we would have to get all of our subspecialists lined up and sports medicine docs, we're used to this, right? We're used to getting a call at midnight that so-and-so's wife is having pain or so-and-so is having pain and needs pain meds. The cardiologists, the EMTs, the guys that are in other specialties don't necessarily have that sense of urgency. So building your team is really key. And I think both of you guys hit the nail on the head with that, is making sure that the guys that you have that are part of your whole team, your ophthalmologists, your cardiologists, et cetera, understand that there's an urgency here. So a guy would come in and I'd have to coordinate a stress echo and their stress echoes were backed up for three weeks. We'd have to get a cardiology eval. We'd have to get labs. We'd bring them in. The orthopedic side was the easiest part. So that, it was kind of a, it was disorganized, but frankly, it was, in the NBA, it was very hard to organize. In college, we had to carry the CU Hoops team for 13 years. We would do it like any other college physical. All those guys would be lined up. We'd have ortho, opto, et cetera, and we would just streamline it. And that was pretty easy to do. We didn't have to do stress echoes on those guys every year. Pre-game, it actually is a little bit easier in the NBA during regular season because the home, for NHL, and EMAC can speak to this as well, and NBA, the home team doc is the doc for both teams. So you don't have to, when you're taking care, you're in your home arena. I know I would always talk with the EMTs, so we'd all meet in the training room before. I knew who was there. I knew their names. I knew who the staff was. I knew who my specialists were. And we always had signals. So when we were covering home games, it was pretty easy. Now, we were covering away games, which was only during playoffs. That's when you would go through what McCarty was describing, which is you meet with the team docs before. Where's your closest ER? What are your capabilities in the stadium? And just get the lay of the land. And I think that's key as you're covering events is to be situationally aware. I love that term. And know what your resources are in every different location. We would always go, I think the other point is every year, we would rehearse our spine boarding, even if it was redundant. And we would rehearse our emergency action plan and go over it just because sometimes numbers change. Sometimes the number of the head athletic trainer, he changed his cell phone because for X, Y, or Z reason, and you realize your EAP is outdated. So we would review our EAP every year. We would review our spine boarding procedure. And for those of you guys that are going out into practice, you may be covering sports that you may not be super familiar with. I had never, I grew up in Miami. And when I got to see you, McCarty's like, you're gonna help me cover hockey. And I was like, I've never covered hockey. And if you've never spine boarded a guy in the ice, that's a totally different experience than spine boarding somebody on a field or on a court. And so you need to realize that an emergency action plan can vary not just by location, but by sport. Obviously outdoor sports carry lightning risk, et cetera. But that was our protocol. So the physicals were always done in complex EAP review, spine boarding review. And then game day was easier just because a home doc always covered the home games. And I assume NHL is probably pretty similar for you. Right, Emac? Right. Yeah. I will say, just listen to you guys. I've been very lucky. I've had both of you guys as partners and I've learned a ton from you guys. I was actually taking notes as you guys were talking. And it's, I think for somebody coming out into practice as a sports medicine doc, it can be overwhelming to think of all these details. So one, I would encourage all you guys to take the handouts because there are aspects of this that you will need to take notes on. But one, it's a very special responsibility to be a team doc and it's a labor of love. And I would think all of us would agree that's the best part of our job. In fact, when the ophthalmologists and the cardiologists get involved, they're like, this is the coolest thing I've ever done in medicine. And so we have, we're very fortunate to be able to take care of athletes and be part of these teams in a way that is far beyond what you see in clinic or in the OR. I was thinking of like what priority of the things you guys mentioned, and you guys both funny, hit on a lot of key points. I think honesty and trust is probably the most important. I think you can't take care of a team unless the players and management trust you and know that you're gonna, you may not tell them what they wanna hear, but they know that what you're gonna tell them is what they need to hear. And without trust, you can't manage a team. And I think we've all been part of organizations or taken over organizations where there wasn't trust in the previous medical team. And it's very hard to build that trust and it takes time. And it takes all the things they talked about, building communication, et cetera. I would say the other probably most important point is developing mentorship. And yeah, I've been very lucky. I learned a ton from Eric. I mean, I was as green as green could be when I got to the university and I had taken care of teams and fellowship. And he really taught me, it's one thing to know how to do an ACL and to know how to evaluate an ACL in clinic. It's a very different skillset to be a good team physician and to learn how to communicate with a player, with their family, with their spouse, with the team. And having a mentor is really key, but being a good mentor or having a good mentor, the key to that aspect is you have to be a good mentee. It just doesn't come. Somebody just doesn't necessarily take you under their wing. You need to be open to it. You need to seek it out. Some of you guys will enter relationships where you're the second person on a team. You're the assistant team doc to a team and you have a senior person who will serve that. Some of you guys will come in and take over a team de novo. I think all of us have had that experience at the highest level. Matt took over the Patriots and had to rebuild that team. Eric and I took over the Avs and the Nuggets simultaneously and had to rebuild the culture and the communication structure, et cetera. But finding mentorship and reaching out, I remember Eric and I both reached out to tons of NHL and NBA docs to find out what their strengths and weaknesses were in their organizations. And so I was just, as I was thinking about this, it was such a great summary that you guys put forth. And I think the other, I always think something Jim Bradley told me, which is there are sharks at every corner. And that he meant it in surgery, but I think it also goes for being a good team physician. There's always challenges out there. People would necessarily have potentially different agendas and always put the athlete number one. If that's your guiding principle, you'll always be okay. No, thanks Armando. That's great stuff. I've got a few more slides to go through, but we had something at the Bruins. So I was assistant for the Bruins as well, the Boston hockey team. And we went to do our backboarding practice, EAP. And lo and behold, it's one week before the season and someone from the maintenance department had moved the backboard and there was no more backboard in the facility. So I'm telling you, stuff happens. It happens all the time. You're dealing with big facilities, a lot of different things going on. You might have a Garth Brooks concert, then you might have a monster truck thing going on. Then you might actually have a sports contest. So there's all kinds of things going on in these stadiums that we are stationed at, but guess what? It's your responsibility. And they're gonna come point the finger at you to make sure that this is done properly. So the best thing, Armando and Eric touched on it a ton, is I've learned more from the ATCs, physical therapists, strength conditioning, nutritionists, sports psychologists, others, they have so much to teach you. And it's the beauty of sports medicine. It encompasses all. And I think you have to be humble. It's not about you, it's about the players. Always keep the player first. Anytime you have a tough decision or you don't know what to do, it's about the player. We're gonna get into that in a second with some few cases. Don't tell the player right away what they have. You may know what it is, but hey, buddy, I know you tweaked your knee, we got it, we'll take a look at it. Now, there's a lot of different ways to approach that. And we can talk about that in the discussion, but usually it's better to gather the information to make sure before you finalize the diagnosis, get connected with your head athletic trainer, the head physical therapist, and then come up with a plan and make sure you get the player involved as soon as you have the information, but you don't have to do it right away. Liberally use second opinions. I love second opinions, love them, love them, love them, but you have to have the ability to check the ego at the door because sometimes and many times the players are gonna go outside to get their surgical care. And you know what? That was okay with me. Come back and I will take care of you through rehab. I'll take care of everything else with that. And instead of seeing them every day after your surgery, you're seeing them after someone else's surgery and you're just taking care of the rehab. It's actually a little bit easier. Don't overcommit, take care of one team and do it well. We get asked to sometimes to do a lot, but this can overcommit and can really be a big drag on your family. Keep a good balance. And there's times, you know, you can do a camp out down in Foxborough or wherever and don't do it. It's very easy to do, but don't do it. They can find you, but you have to spend enough time. You gotta spend a lot of time down there, but don't do a camp out. Outside of medical care, conflict of interest in sports, I wanna touch on a few more topics, prescribing and some of the other things that's gonna come here. This was a, in some ways, a very disheartening study for some of us that were taking care of football. It was a study that was commissioned by the NFL Players Association. And what their goal was to protect and promote the health of NFL players and really come up with the ethical analysis and recommendations. And they made a lot of recommendations from the stakeholders, described legal and other obligations, evaluate the sufficiency of the existing obligations and current practices and see what we can do better. But these are basically what we do as a club doctor, providing healthcare, return to play, during help clubs overall get their players better, getting a competitive medical advantage if you can help them in the injury and wellness and getting less people injured, and then helping physical condition determinations. So there's a lot with this. And the 2016 Harvard report, again, which was commissioned by the Players Association was to look at some, potentially some of the conflicts because there was a little bit of disgruntledness going around that maybe the team physicians were at least being perceived as having a conflict. Clubs were requesting players to go elsewhere. Agents were requesting players to go elsewhere. And so what came out of this, there was actually quite a bit that just helped us, I think, refine how to make sure that we're doing the right thing. For the most part, many of us are doing the right thing. And we'll go over some of this a little bit, but you can see, this is a very interesting read. There's some good summaries on the internet if you're interested on it, but it does talk a lot about the ethical and conflicting that is apparent everywhere, conflicts everywhere. Who's paying, if you're getting in a job where who's paying your paycheck, club and owner, how does that affect your judgment? We have AMA standards and AOS standards. There are standards on marketing agreements, and there's sometimes big dollars from an institution or a practice to be able to market that they take care of Team X. And there are some standards of professionalism on that in terms of how that has to be done properly. And so there's not a quid pro quo. Legal obligations, ethical obligations are very important when you look at this. Your role is to, again, take care of the player. You're independent for the player, but you're still for the players. You have to inform the patient about what could be discovered during examination if there's issues. There's a lot of ethical things that can come into it if you find something and how you disclose that to the team. Fortunately, many of the pro leagues, players have signed HIPAA agreements and other agreements to share their healthcare information among providers that you deem fit. But again, it's a very special privilege that we're given as team physicians to have and safeguard that medical information of a player and know when it has to be released and who it has to be released to. This was an important thing. So if you were taking care of a team and McCarty or Vidal were having to go to California and they were covering a football game at UC in the PAC, well, Eric McCarty back in the day was sort of practicing medicine in California, but didn't have a California license, meaning he was taking care of his players, might've been prescribing medications, might've been giving medication, might've been giving medical advice, but this was really important. And AOSSM was at the forefront of this and the team physician committee. And this is a huge, huge thing for us, which really got fully signed in 2017 and then really put into final action in 2018. And this basically now says medical service provided in a secondary state, meaning McCarty and Vidal traveling to California will be treated as they were occurring in the primary state, meaning as you were licensed in Colorado. If, there's a caveat, the secondary state's licensure requirements are substantially similar to the primary state. I haven't seen any case law or anything that has challenged this or what states are substantially different. We can talk about that in the questions, but you can now engage in the treatment of injured athletes across state lines without fear of professional harm. This was a big deal. And if you look at T. Mormon's statement, previously the circumstances for treating our athletes during a game was different, didn't allow for optimal care to be provided. Now with this legislation, team physicians can now give the exact care to patients no matter the location and without fear of license violations and repercussions. This is a big win for the treatment of our athletes. So this is really big and AOSSM was really at the forefront of this. Just, I wanna touch on this. We can't do everything on injections and game day management. I do wanna hit some things that you're gonna, this is gonna come up right away. One of the things I personally didn't like doing and certainly would love my panel's opinion on this as well as narcotic pain medications. It used to be back in the day and when I inherited one of our professional teams, we actually had a safe in the athletic trainer's office and we had a narcotic log. Unfortunately, we got away with that. We did away with that. We try to avoid narcotics except for the times you need it. Fracture, acute injury, really bad sprain, you need that. But I think the best practice is that, that we change. And I think this is now the go-to way to do it is provide a prescription to the athlete. Give that prescription to the athlete and then they go to the pharmacy and pick it up and give a small amount, five to eight tablets and then revisit it. Athletes will ask for this and there's all, we know all the issues in narcotics. There's a reasonable study that looked at some basketball reflex ability and it was decreased to 28% reflex ability for people that were just on two Norcos a half hour before the game. Now, this has gotten us in the press from an ethical situation, us collectively as team physicians. So we have to do better. We have to ethically be better and we can't push these painkillers on players. And this is where the ethical dilemma comes in, you know, especially if you've got, you know, a coach that might be riding you, a general manager that might be riding you and then you get into something a little less. Well, Toradol, Ketorolac. JT and Rich Hawkins put this study back in the day. There were 28 out of 30 before the 32 team expansion responded to use Toradol. 20 out of 30, 24 out of 28 would allow a player as much as a one injection at least once a week throughout the season. And then most team providers felt that Toradol and the team physicians were at its use. I can tell you that has been the culture in the NFL for a long time, but from the National League Physicians Society mission to use, it's widely believed that this Toradol uses an increase in plevums, but also has now trickled down to division one football. But this recommendation will only administer in the direct supervision of club doctor and it's not used prophylactically. So you have to document acute pain. You have to document the acute need for the pain. And that is the white label recommendation from Toradol. That's the white label mandate from Toradol is that you need to have acute pain. So that's the key here. And I would really recommend against the use of Toradol if at all possible. And what we have switched to in many of the organizations is naproxen, Aleve, an anti-inflammatory. There are some concerns with that about the theoretical bleeding and some others, especially in contact sports. We can talk about that in a few minutes, but again, we're really trying to discourage the use of pregame medications. Injection is a little bit different. There are certain things that are good injections. We can talk about that in a few minutes. So NFL clubs after 2015 do not store or provide controlled substances to players. You can prescribe it, but it's filled in a local pharmacy. So it's just like anything else. And guess what? Have your dictaphone or have your EMR or have your laptop with you and you're pulling it out in the athletic training room and you're documenting everything. Where can we improve? Here, the pain medication is a big problem. 71% of these players reported a misuse of the drug. 37% of all players reported a misuse opioids during their playing careers. This is a big problem and we need to make sure we're at the forefront of this. It's getting better. Before we get into this, Eric Armando, talk to us about your take on pregame medication. Not talking ankle fracture or something like that, but pregame medication. Tell me, they say, doc, my hip's been killing me for 10 weeks. Eric, what do you do? Well, you know what? We wanna know what's going on. You know, we want a diagnosis. And so, you know, the worst time to treat somebody is if they come right before the game and say, hey, doc, this has been killing me. So in that case, you know, they come right before the game and doc, my hip's been hurting me for 10 weeks. That's not the time to be trying to figure it out and trying to medicate it. Now, maybe it's appropriate to have some Tylenol. We're not gonna give much more than that or maybe some naproxen, but we really wanna know what the diagnosis is. And that's key, no matter what the issue is. You know, and we wanna know what's happening because it's really incumbent upon us to help these players out. And that's where that trust comes in, that they will tell you, not right before the game, but they tell you during the week or the weeks going into a game or whenever it's going on. And hopefully they have that trust with the athletic trainer as well. Armando? I'd agree with that. You know, we didn't have any narcotics in the training room, obviously. You can't travel with narcotics across state lines, just as an additional point. That's a federal offense and that got a lot of attention when all that legislation was coming out. But so we didn't have narcotics in the training room. Our philosophy, and I'm sure your guys' is the same, is if anybody's got acute enough pain to require narcotics, which is usually a fracture or post-op, they are too painful to play. So, you know, obviously we didn't give them, we would treat them like our own patients, give them a script, they'd go to the pharmacy, they would fill it. And obviously until that acute event was gone, they couldn't play. We would not use anything more than Tylenol, maybe oral anti-inflammatory like Aleve or Advil. With the Nuggets, we never used TOR at all. We were already out of that era. We did use some, I would say, early at CU, decade plus ago, and Emac can speak to it too. We had some press attention when all this was getting, but we've gone away from that as well. So I think there may be a role for local anesthetic for certain injuries. Like AC joint is a perfect example in hockey, in college hockey and professional hockey. You know, that's an injury where they can limit their ability to play. There's really, I think, little risk to further injury, to numb it up and get them through a period. So there's limited role for local anesthetics, but it really has to be a condition where it wouldn't deteriorate if they were continuing to play on it. So I share Eric's perspective, which is really limited use for a known injury that you're actively managing. Right, and well-documented. So Armando, you reminded me of one of my least, one of my least favorite times in the last about six or seven years. I don't know why all these people have it out for the Patriots, but we were leaving an undisclosed, we were leaving an undisclosed away game, somewhere not in Foxborough, Mass. And we're there, the medical team's there, and all of a sudden we're about ready to get on the bus, and about six blue coats, classic button-up with the yellow DEA on the back, show up and grab us. And went through, it was about 2015, went through all of our stuff and went through everything. But this was the start of a very long process of the DEA out of the New York office was pursuing a whistleblower complaint, basically, of traveling with narcotics across state lines. Of course, we weren't, fortunately, but of course it opened up all kinds of doors and opened up Pandora's box, unfortunately, in terms of how we were doing things. Unfortunately, there was no issue at the end, but it's just not, it's the real deal. So when you're getting snatched by some DEA agents in an undisclosed location trying to go home and you're delayed, it's not that great. The other thing that was going on around the same time, and it's public information now, but we had a lawsuit that was going on with a well-known player out of California, and also in the NFL, they claimed Toradal did harm to his career, caused all kinds of health issues and all kinds of other stuff. So again, what was the best thing for us there was the documentation. It was settled for a very small, minuscule amount after some of the longest depositions I've ever been through in my life with about 25 attorneys sitting around the table. So it's a real deal. Unfortunately, you've got good documentation. You talk to them about the risks. You talk to them about what was going on. It's, you can, that's the best practice. So with that, I know we got some, so we got some time here before we get to some of the questions at the end. I want to go through some of these cases and Armando and Art just chime in. Case one, the injury before the big game. I just put some of these together. These are all sort of theoretical. Some are not, some are real. Just changed a little bit of the scenario to protect people. It's a 17-year-old female, senior fall, captain of the state-bound champion soccer team. Knee injury, pain, swelling outside, effusion. You suspect a medial meniscus tear. The ACL feels pretty good, but it is causing her some mechanical symptoms. It is effusion. She wants to play the state championship game next week. Eric, what's your call? You know, my call, I want to know what's going on. We're going to get an MRI and then I can counsel her. You know, maybe she has a small little piece of cartilage, maybe a meniscus. Maybe it is something she can play, but maybe it's not. And I want to know that. I don't want to just let her go without understanding what the issue is and how to counsel her better. In my mind, this is, you need more information. For some people, they would say, nope, absolutely could not play. And then some people would say, well, yeah, just let her play. I really want information before I make any determination because you want to counsel both the player and her parents. She is 17. Her parents are going to be involved with this. And you want to do what's right for the long-term. So Eric, the MRI shows partial meniscus capsular, shows a moderate effusion, just like she has an exam. It's Wednesday, game's Saturday night, down in one of the big stadiums. She's been waiting her whole life to play. So if it's partial meniscus capsular, you know, there's no way that I'm going to do any kind of numbing, no lidocaine marking, no cortisone. She's going to be self-limiting, might drain a little bit of the fluid. Can she run? Can she do everything? Can she be safe? Those are going to be paramount. If it looks like it's impending, complete tear, something like that, then the counseling would be not to play. But sometimes you get an effusion and it's just a tear of the capsule, right? And so I want to know that. And I think in this scenario, you know, again, I may suggest that we can see how she does. You give her a couple of days, as long as she can run, plant, and do everything she needs to do without further injury or potential further injury, I might let her play. Some kind of on test. I agree that test is something we'd always do. But yeah, Armando, go ahead. I would say I agree that there are scenarios. I had a girl just recently, basketball player with an acute chondral defect, lateral femoral condyle. It was definitely one that you, I mean, I didn't feel comfortable letting her play, but she said, you know what? I'm a senior and I just want to step on the court. You know, so we put her in a lateral loader brace. She knew she couldn't play. She just wanted to step on the court and shoot one shot. You know, they fed her the ball from the three point range. She took one shot. She immediately blew, but they called the time out and took her off the court, just to say that she played in her senior championship game. So sometimes they're hybrids. And I think, you know, like Emac said, being situationally aware, sometimes it is an injury these kids can't play. Like they can't play that soccer game at full capacity. They can't play that basketball game, but it's really meaningful to them to be able to step on the court with their teammates. And so sometimes there's an in-between too, between letting them fully play and pulling them and satisfying, this may be the last time this kid ever plays soccer again on a competitive team. And so I think there is a gray zone here too, but I think you just need to be mindful of that scenario if you think you can do it safely. Yeah, so real case here, it was a meniscus capsule. It was a little bit more than partial, but you know what? She went and played the first half and did actually quite well, got into the second half and had to come out. But you know what she that that was her for her. That was it. And you know, the good news is we actually did repair it. There was no additional damage. But those are the things you have to talk about. And that's the things we documented, you can make this worse, you can chew this up, you can make it unrepairable, and something that, you know, continue to be a problem for us, we ended up repairing it. So how about the pro injury is a vision offshoot the pro injury before the big game tenured NFL veteran sentence injury because of ACL tear following the AFC championship is considering retirement after the season wants to hide the injury or start in Super Bowl game has to undergo imaging full examination after the end of the season. Of course, you've had your hands on this player's knee. Can't confirm or deny if this is a real case or not. But what do you do Armando? You know, it's tough at the end. At the end of the day, these are still patients. You know, as you mentioned, first, the patient is your paramount, you know, that just like your patients in your office, so you can't force them to get an MRI, you can't. I don't think you can necessarily tell the team. If he doesn't want to disclose it. This is where trust comes into play, right? This is where you got to sit down with the athlete behind closed doors, without the athletic trainer without the PT, and have an important discussion about what the consequences are. And I think these are these are real world decisions. I mean, I think, in the ideal setting, you convince him to get imaged. And, and, I mean, if he's got an ACL tear, I think that he's creating long term damage to his knee by playing in that Super Bowl game. But I've never played in a Super Bowl game and don't realize what the significance to him as an individual is. So it's, I think this is a tough one, man. I don't know if there is a right or wrong answer. I think your best answer is to use that that relationship and, and try to advocate for him and give him the best advice that he can. And hopefully, you guys come you guys are aligned with that approach. You know, but but I've certainly been in scenarios where athletes are like, I don't want to know until the end of the season. And, and you can't force them to do it in that context. So it really is about the relationship in that context, in my opinion. So Eric, you had your hand on hands on his knees. Okay. You know, it's a 2B Lockman. He's got moderate effusion, small to moderate. He probably had, you know, when you really look at he might have had a, you know, an acute on chronic ACL insufficiency, but certainly, the straw here was broken. What do you think? You know, I think the points that Armando brought up are really valid. I you know, this is this is not going to be only you, it's gonna be you and the athletic trainer, really. I mean, the athletic trainer is gonna know, you're gonna know. And I think you talk to the player, and it's going to be self limiting or not. I said, Okay, all right, you want to, you want to try and go out there and you've got to prove to us that you can, you know, do the things you have to do. And if it's truly maybe a little bit of chronic issue, if he's a lineman, he actually might do okay in a brace and get through a little bit. But you know, I would, I would basically tell him that I, I think you need to understand what's going on. You need to understand the ramifications of what might happen. And you need to go out there and prove it. You can't just go out there and walk on Sunday and say, here I am, you've got to do things ahead of time to prove that you can do it. Yeah, that's exactly what was done in this case. A player, player got through most of the game, it was a, it was a lineman, fortunately, it was braced. And played, played in the Super Bowl, his first Super Bowl. And so at the end of the day, was was very thankful. Got through three quarters. Now what's interesting here is we actually, you know, through the athletic trainer, started first with his agent and his parents, because he wanted to keep it confidential. And I chatted with him. I'm like, Listen, you know, here's, here's the deal. This is what you got. I don't know the MRI, but your knee is loose. And it's different. And it's swollen. I mean, there's, this is what you got. So, you know, they, they acknowledge that. And I said, Listen, I just I need, you know, because of it, because of safety, because of the stakes of this, I need to, I need to get the team involved. I just need to do that. And they were okay, after, you know, talking about all that. So again, it's, it's that it's kind of that trust and the relationship that you have. And we had a great relationship with this player, I had a great relationship with this player. And so it did all work out fine in the end. But, you know, certainly hours and hours of my time dealing just with this one case before the Super Bowl. So you have to be prepared for that. You know, just like you said, is that trust, right? So the athlete trusts you, and management trusts you. So you can be the advocate for that athlete in that context, right? Where you can go to coach and say, Look, this is a scenario, it obviously it's going to need attention. But, but I think he can get through it. And you can advocate for his goals. And it's trust on both sides, right? It's and that's, you got to build it with management with the team with the players individually with athletic training. So your relationship with those different players is what allowed that athlete to play in the Super Bowl. You know, you brokered that essentially, and that communication, too. So I think it's it goes all of it together, like we talked about before. I mean, you had great communication, your lines of communication were very open. And, and that goes with the trust. So I, you know, that just speaks to your relationships. I slept so well, I didn't sleep well, at first, I'm like, Oh, how are we gonna hide this? How are we gonna do this? None of it, none of it worked in my mind, you know, and the integrity of this. And then when it all came together, and you're able to do this and broker it with the trust and do it, right? Listen, I have to tell the team, I have to tell management, I got to tell coach, it's just not right, it's stakes are too high. Now, I can be your advocate, just as you guys said, it's perfect. Now, let's go on to this one. It's case two, don't let them know. NFL Combine had 330 players come to Indianapolis every February, they get an invitation. And during that time, they get walked around numerous rooms and in private to one of the medical docs there, one of the players disclosed a bunch of unreported concussions sustained throughout college, but doesn't want to include the official medical report and says, Oh, no, I don't, I don't really mean that, didn't really mean that. Now, what they, what this player did have on the medical report was two concussions, because they all know if it's more than two, then we start looking at things a little bit closer. Eric, what's your call? You know, so this is, this is a little bit different, because this is not your athlete, this is not a physician, patient relationship. This is, you know, this is hundreds of athletes with dozens of doctors going through this. And, you know, basically, he's asking your advice, but at the same time, you know, he is disclosing this is a combine, this is, you know, basically, they sign waivers that any information that they, that they give goes on there. And so I think at this, this type of thing, you know, it has to be disclosed, at least on your on your portion of it, but they're gonna, he's gonna be talking to a bunch of teams, maybe on the team that you're, you're covering, your team has to know, I mean, there's no doubt about it. Yeah, there's a lot, I didn't want to get too much into the combine. But you're exactly right. And that's what happened. I think if you know, they're talking about it, and it's in the, again, it's, it's, it's hard to say, but it's in the best interest of the player at the end of the day. But the problem is, you know, you could have cost this kid 5-10 million dollars if they go down the draft round. Matt, you it's interesting. So I agree with you, Matt. I mean, obviously, your duty is very different in a combine setting. The NBA as a league has kind of caught attention. So very different than the NFL and the NHL. They don't let the doctors technically communicate. So like, if, if an athlete told me that as a Nuggets doc, it happens, but they've discouraged me from like talking to San Antonio stock, or, you know, Celtics, and disclosing that, because they feel like an athlete can get like a red flag. And so they have actually really, their concern is that we as medical professionals are hurting their ability to get drafted. And so it's, it's, it's really hampered the combine process for us. So like, in the NBA, if that happens, technically, I can disclose it to my team, because he told it to me, but I'm not supposed to disclose it to another team. Yeah, it's the combine process is continuing to get refined, but there's a lot of data and a lot of information there. So it just, it's something, it's something to think about. And I think it'll be refined by the time everyone probably on this call that's involved with it as well. Let's do this one. Case three, the not so bad kind of play through at injury. D3 rookie, college, seems leg injury in practice week before the playoffs. Had prior complaints of intense femoral, femur pain throughout the season. Imaging demonstrates some stress fractures up and down the femur. And then been playing through it. Team coach, the reader imports upcoming game, ask you to mask the pain with something. Let's not say it's opioid, even naproxen, or toradol, or a vitamin T injection. What's, what's your call Armando? I think this is one where it's a hard no. I mean, this is, this is an injury where continue to play through it has severe consequences, right? Risk benefit ratio. I don't, this is a, this is not a not so bad injury. This is one of the few that can result in really catastrophic consequences for an athlete. So I think this is one where educate, I mean, the athlete's not going to like it. The coach may not like it, but this is, this is where your knowledge and experience really comes into play. And this isn't an ankle sprain that they can cut and pivot on. This is something that is going to be a problem. So I, in my opinion, I, so again, I would never let an athlete play a narcotics. I think if it's bad enough for narcotics, they can't play. But regardless, this is a, this is a hard pass. This guy is going to be shut down. Yeah, it was pretty, I think it was something more minor, like you said, or maybe a minor stress fracture or small tibia thing, you know, maybe, but again, these, these stress fractures can be, can be dangerous. Of course, it's very situationally dependent of where it is and what the context is, but that player did not play. The final push, professional lacrosse player, part-time pro, a lot of these professional lacrosse player works as a consultant, but multiple injuries also does a consultant, but does a lot of CrossFit and all kinds of things. And a lot of pain in his hip back says you cannot play unless he has an injection. He calls it vitamin T, vitamin Toradol pregame, just like McCarty used to give it to me. He needs it to play as they head into playoffs on the bubble team and they need this win. It's professional lacrosse league and it's a brand new league and it's pretty cool. And they got some TV following now, you know, but you know, McCarty used to give it to me, doc, what are you going to do now? Armando. Ah, God, I mean, I think it's, you know, throw McCarty under the bus, like you said. No, I mean, I, I mean, I think Toradol is an anti-inflammatory, like a lot of, I mean, I think this is, this is one where I would prefer to use orals and, and to see if he can control with oral, you know, NSAIDs that are conventionally used, et cetera. And I would, you know, try to educate them that they're the same in terms of their efficacy. And, and, you know, so I would try to avoid Toradol. I, I mean, I don't think Toradol is the evil that it was made out to be in the media, frankly. So, but I, I would prefer to avoid it in this context, particularly given the press and the optics. Eric, what do you think? You know, that's interesting. It would have been a long time ago that he played because he's a master's athlete now. He is about as old as me. But the, you know, this is real scenario because I, I've seen this in some of the guys in the pros, not so much in college because, you know, they're coming from high school and, and they're not used to it and we don't give it. But these guys in a pro, well, hey, this, you know, I, I got it when I was in the, in Canada, in the, you know, in the, in the minors. And, but, but it's a hard no. We're not, we're not doing injections of Toradol. We just don't do it. And so it's a hard no. We'll try to provide a, a substitute. We're okay with the, with PO Toradol or Naproxen or something like that, but we're not doing injections for, again, for the, for a lot of reasons. And, and one of them is the, the, now the way it's looked upon with the, the, the medical legal side that's come up from all these different, different lawsuits and things like that. But also we don't want to get somebody into that rhythm of thinking that they need this because that was a big thing with Toradol was not so much to help them feel better, but then they just, they wanted it every game because they thought they had to have it even when they weren't hurting that. And that was, it was the psychological dependence more than even what it was doing that would cause a lot of problems. And in the days there used to be 30 guys on the NFL team that would line up for these Toradol shots. And fortunately that's, that's gone away. Yep. I call it just like mission creep. I call it an injection creep and they start to feel that they need it all the time. Yeah, Matt, I would, I think just, just because it's an oral anti-inflammatory too, I think you need to be mindful. We, you know, the culture of the Nuggets before I took care of them was that the athletic trainer would just give it to the athletes when they wanted. And there was no oversight. They felt because it was over the counter that the doc didn't need to be included. So we had to change that culture, going back to what you said, it was, we needed to be aware. And there were cases of high profile NBA athletes with like, you know, glomerulonephritis from chronic NSAID use over years. And we had to, you know, pretty prominent athletes. So we had to dial that back. And every five days we needed to get a report. Like if this athlete was still on NSAID, why are they still on an NSAID? Do they need to be on an NSAID? Who's checking the renal function? I'd also, for the young guys, as they take care of more elite level teams, you need to be aware of what's a banned substance and what's not a banned substance. We had an athlete who tested positive for ketamine. I got a call from the league office and said, you've got an athlete who's positive for ketamine, which is obviously also a recreational drug. And I was like, gosh, this is a challenging problem. And I went rifling through, we had just taken over the team like two months before, rifling through the cabinets in the training room. And there was a topical, like one of those meds that are blended that are, and had ketamine in it. Thank you, that's what I was looking for. Compounded cream with ketamine in it, and he had gotten treatment for patella tendonitis the day before his test, and he triggered a positive test. And that was, again, a legacy of the previous medical staff. So you need to be aware of the stuff that sometimes they're using without your awareness. And even the common things like NSAIDs can be problematic if used excessively. Good. A couple more case. So case five, I call this the parental crockpot pressure cooker. A 14-year-old male plays baseball as a pitcher. Got a major tryout in two weeks for USA travel team. Plays baseball 13 months of the year. Pain and throwing shoulder off and on the last six months, but you just learned about it first time you're seeing the doc. X-rays confirm some ficeal reaction, but it's minor at best. You can sort of get the sense a kid really doesn't want to play, but even in the office, the parents are coaxing him to play. Come on, Joey, you've done it before, and your team needs you. Eric, your call. You know, this is where, you know, I tend to really try to protect the player. I mean, that's what we should do anyway, but, you know, he's a 14-year-old, and that's tough for him. You know, he's telling you, or you get the sense that he doesn't really want to play. This is where, you know, the art of a team position comes in, and, you know, basically, you tell the parents that, you know, he's got a stress fracture, you know, probably small one, but he's healing from it, but it's not going to get better unless he has rest, and that's really the case, and again, he doesn't want to play, and Matt, you know, you've been such a great advocate for looking at youth sports and avoiding, you know, the super specialization of sports, and here's an example of it, you know, just, you know, playing 13 months a year, if I read that right, Matt. That's what's happening a lot right now. We have to be very careful. Can you hit exactly on it? The ESS, early sports specialization, is a huge problem. It's certainly a pet peeve of mine, but it should become a pet peeve if it isn't already of all of us on this phone call. We have to be watchful for this. We have to be mindful the data's there. That's a whole other discussion beyond tonight, but this is a classic example. Yeah, and you're protecting the kid. You're protecting the athlete. The hard thing is if, you know, if he wanted to play, and he's still got to protect the athlete, right, but he clearly is probably tired. He doesn't want to, and how many times do we all have somebody come in our office, and the parents just think the kid is going to be an All-American. He's going to the pros, and most of the time, that's not the case, and so you got to protect the kid, so this is a no-go plan. I try to send those to the All-American Dr. McCarty, but sometimes it doesn't always work. No, you know, so it's interesting, you know, so they storm out of the office and found another opinion. Very interesting. Matt, you know, I think for the people on the call, that's a real, it's not, these aren't just clinical vignettes that are theoretical. These are all real. Every single one of these is real. Yeah, I had a kid. I had a hockey player with a patella fracture, and like a vertical patella fracture, so relatively stable, didn't need surgery, and the mom, the dad, I told him he couldn't play. The dad says to the wife, you know, this is about Johnny's knee, not about Johnny's hockey, and she's like, no, this is about Johnny's hockey. This kid had a fracture. I mean, this, these are, we all see it. These are really real phenomenon that occurs. So again, complex, you know, a lot of emotion, a lot of stuff, all this stuff thrown on you. They try to stress you out. Divorce, all of that. What's the best thing for the athlete? That's the easiest question to answer, and then you'll almost always be right, and there may be some other things you have to do to massage that. What's the best thing for the athlete? Last case here, the sneaky GM, a 22-year-old second-year pro soccer player, female. She was one and a half weeks into a concussion protocol, needs at least three to four weeks to progress through. GM is stalking you at your car in the team parking lot, waiting for you to leave and finish your training room. Knows when you're leaving. Hey, doc, really need to get her back to play this week. We got a big game. We got to get back. You say, well, you know, she won't be ready. GM says, well, that's too bad. We're getting another opinion, and also, you have to remember, I get your kids tickets to every game front row. Eric? I mean, you know, this is, there's not even an issue here, Matt. I always would agree. The kid's not playing. They're not ready to, and this is an example that I talked about, that basically, you've got to have good communication with your management, but who makes the call and return to play? Who makes it? It's not the coach. It's not the family. It's not the agent. It's not the general manager. It's you, and I, the athletic trainer, we work as a team, but you know, hey, I'll sleep a lot better at night knowing I did the right thing rather than going into the GM in terms of what they want. Armando, what do you say in the parking lot? How do you handle this? You know, I think you could be a coach in college, a coach in high school. How do you handle this? I think you, you know, I think you can maintain that relationship. I mean, the GM is putting you in a very difficult position, right? Like, clearly, they're not aligned with your vision of how to take care of this team, so, but I think you can do it in a positive way, right? Like, how do you, how do you bring them back to your position without making them feel like you're disagreeing with them? And, you know, so you say, I think that's a, I think that's a great idea. I think a second opinion is, is, I'd encourage that. Hear, hear the names of two or, and you, you direct them to people that you know are going to be like-minded to you, that you know are also going to say that athlete's not going to be able to play, right? And you say, I think a second opinion is a great idea. I think a lot of these things are controversial. I, you know, you got to remember the optics of concussion and, and how you're going to appear in the media, but I think, you know, making sure we're going to make the athlete feel like they're being taken care of. And then, you know, why don't you see this neuropsychologist here in town as an expert and world-renowned and takes care of the NFL team in town too. And you know that that neuropsychologist is aligned with you because they're the ones who write all the protocols. So I think you can redirect this in a positive way and still get your outcome and not make the GM feel like you're just barreling it down their throat. And I mean, that goes for a lot of relationships in life, but that's probably how I would handle it. Yeah, no, it's interesting. So with this one, exactly, I was handled and, you know, you can, you know, be, be very professional, always be very polite, you know, stick to your guns. You're the doctor, you're the head doc, you know, that's what you're there for. You're there for the athlete. Again, what's the best for the athlete? What's interesting is there's usually some other things going on. You don't have to dissect it out, but, you know, come, come four to six weeks later after this, the GM was actually like, oh, the GM was on, GM was on the ropes. And so it's not really a great, when it's not a great person, it's not the best for, you know, these really high level women that were playing soccer. So there's other, usually other things and other baggage going on. You know, you don't always need to read into it, but again, you get stuck by your guns, the integrity, and that was the right thing to do. So I think the future is exciting. It's ever evolving. They must continually learn in advance, keep up, train, train, train, practice, practice, practice. Your team will love it. Take them through another EAP, take it through it again, do it again, do all the training. You're going to have to be more sophisticated and better trained than ever. And we don't even have enough time to get into COVID tonight, but that's a whole nother two hour webinar and what's going to happen there as this whole thing unfolds. But guess what? It's going to come on the team position among many others. And this is going to really be important. New sports is going to be more and more important as we continue to move on. And this is Eric's last side, last thing. And what we do is presenting a lot of stuff here, but this is really fun. It's why are we going to sports medicine? Enjoy what you're doing. We have a great profession. So blessed to do the work we do. So fun being a team physician. So Meredith, I think, do we have questions? Yeah, there's one question that was sent through. I can ask the question. Go ahead, please. Yeah. It says, may I ask one question from your experiences as a team physician and surgeon? How can you determine when your patients athletes are fit and safe to return to play? Eric, go ahead. You know, that takes the communication. And typically, if you have a team, then you're communicating with the athletic trainer, you're communicating with any other specialist. And so, you know, basically, we want to make sure we have this great communication, you know, the athletic trainer, the coach, the strength coach. And so, say example, it's an ACL. And you're trying to determine if they're ready to return to play. The athletic trainer is seeing them all the time, or at least a lot of the time, the strength conditioning coach is seeing them quite a bit. You may have some testing that you do, some protocol. And then the last aspect is, and we're fortunate that the University of Colorado, also a lot of universities, you often have somebody that's really a specialist in mental health. And nowadays, and I would say, really is the case with a lot of athletes, the mental aspect of it is huge, because they may look physically ready, they may pass all the testing, but psychologically, they're not quite there. And so, it's a team approach to return to play. And, you know, I think it goes back, Matt and I wrote an article on return to play after ACL, and there's a lot of factors that go into it. It's just not one factor. Armando? Yeah, 100%, I'd agree that. I mean, I think you really need to rely on your, you know, expertise and whatever the ailment is, right, in terms of the prognosis and, you know, what the appropriate recovery time is, whether it's a meniscus repair, an ACL, a shoulder stabilization. And then like Emac said, I think it's criteria based, you know, I think, you know, ACL, for instance, is great, because we have a return to play criteria that's functional, there's RSI, which is the psychological readiness to return. So, you know, I think it's multifactorial. But the first thing is just your understanding of that injury with your experience and knowledge as to when they should be able to return following their recovery, and then using whatever objective metrics exist for that particular injury, right, like functional tests, can they cut, they pivot, can they can they sprint, etc. So, you know, that's the art of being a sports medicine doc, right? It's not a, you're not a robot, you're not just saying, you check this box and this box, there's, there's a nuance to making that, that decision. But, but the foundation is your understanding of that ailment and appropriate recovery. Excellent. Well, hey, I want to thank my distinguished panelists. This was a great discussion, a lot of fun talking about this, you know, we're all, we're all very passionate about this. And I know as you finish, you know, finish your fellowship, you're, you're going to have an opportunity to do this sooner than you think. And it's going to come in September. And you're going to be thinking about the backboard and the EAP and everything else. And, but it's, it's so much fun to have the team and do what we do in sports medicine and taking the best care of our athletes of all ages. So with that, I want to thank you want to thank AWIS and SAM, I want to thank OSER again. And lastly, Meredith, thank you so much for your incredible organization. Everyone have a great night. Thank you. Thank you guys. That was fun. Good night. Please call if you have any questions. Thank you to the panelists. Thank you, Dr. Bacardi, Dr. Provencher and Vidal for your time and preparation for tonight's panel. Thank you, OSER. Listed here are resources for, for the attendees. All of the slides are available for download in the handout section. If current fellows have not already applied for AOSSM candidate membership, the application fee is free for current fellows and covered by OSER. You may apply online at the AOSSM website. Next week's webinar, we'll highlight high-risk ACL patients with Dr. Robert Leprod, Dr. Andrew Gieslin, and a special guest. Thank you. Good night. Great. Thank you all. Good night, guys.

webinar

team physicians

sports medicine

communication

preseason physicals

emergency action plans

ethical considerations

continuous learning

returning athletes to play

mental health

collaboration

patient health