Cook Drops The Ball

This week’s guest columnists are Drs. Jordan Conway and Amir Farizani, Family Practice residents at the University Hospital and Clinics here in Lafayette.

Watching the instant replay, I saw exactly when Jared Cook lost consciousness.  In yesterday’s Saints game against the 49ers, he made a great catch, and hung onto the ball through his fall.  But as he lands he’s hit in the helmet.  His hands go slack, and the ball rolls away. To return to play, Cook will undergo daily neurological evaluations while his brain heals. Then he must stay well under increasingly challenging conditions- during exercise, then drills, then scrimmaging.

Concussion is defined as a brain blow followed by loss of consciousness, headache, nausea, trouble with balance or coordination, memory loss, disorientation, and slowed thinking.  Bright lights and loud sounds can make it worse.  Irritability, depression, anxiety, and mood swings are also part of the picture.  Concussion isn’t brain bleeding or skull fractures.  It doesn’t show up on scans- it’s simply defined by the symptoms.

It’s important to immediately remove an athlete with suspected concussion from the game. Continued blows can worsen the injury; prolonging recovery, worsening pain, and even risking brain swelling and death.  It’s sometimes a while before concussions are obvious to coaches, or the player himself.  Thus with any suspected injury, the player needs a sideline evaluation with one of several tools approved by the league- NFL, NCAA, LHSAA.  Don’t wait until the player is staggering about, slurring his words, and vomiting.

If a player is suspected to have concussion, that’s it for the game.  He needs a more thorough evaluation by his doctor, plenty of rest, pain medicines, and time.  The doctor determines fitness to return to play.  Sometimes the simplest things can bring headaches back- trying to read, math homework, exercise.  It can take weeks for an athlete to be ready to play again.

These rules go for all sports with head injury risks- soccer, cheerleading (lots of throwing and falls off pyramids!), basketball, baseball and softball.  No one’s invented an attractive cheerleading helmet yet, any takers?

Kids are constantly bonking their heads, like when my son was learning to walk.  He would take steps along the couch, holding on for support.  Then he’d toddle away, swaying back and forth.  Once he tipped forward and smacked his forehead on the floor.  My wife squeaked, snatched him up, and looked to me for help.  I froze, mouth gaping. Oh, right, I’m a doctor!  Then I remembered my time in the Pediatric Emergency Department.

In the ER we have guidelines about which head injuries are fine, and which need CT scans for brain bleeding.  There’s separate guidelines for kids under 2 years, and those over 2.  My son was in the under 2 category, so these told me he was okay: he wasn’t knocked out, crying immediately after flopping down. Then later he acted fine. This wasn’t a severe injury mechanism, for his age meaning falls greater than 3 feet; he’s under 2 feet tall.  He had no scalp swelling or other signs of a skull fracture.  Thus I knew he didn’t need an ER visit.  Myth buster- no need to wake him up every hour at night to check on him either.

The criteria are a little different for kids over 2.  Notice I didn’t worry about vomiting in my son.  Toddlers vomit easily, especially when they’re upset.  Vomiting has no correlation with bleeding at that age.  However, over age 2, vomiting is on the worry list.  Other signs are being knocked out and/or having a really bad headache.  Indications of skull fracture are “raccoon sign” (black eyes without a blow to the face) or “battle sign” (bruising behind the ears).  If the child is acting dazed and confused (worse than usual, for your teenagers!), that’s concerning.  Finally, if there’s a severe mechanism of injury, like falls greater than 5 feet, blows by a high-impact object like a thrown baseball, or getting hit by a car while walking or riding a bike without a helmet, get checked!

We don’t CT scan every kid who comes into the ER with a smacked noggin.  CT scans carry a small risk of causing cancer by their radiation dose.  We see all severities of injuries, and with experience and these guidelines can make the scan-or-not call with a cool head. If your kid needs it, he’ll get it.  If not, whew!

Play ‘Til It Hurts

This week’s guest columnist is Dr. James Hyatt, a family practice resident at the University Hospital and Clinics here in Lafayette.

“Winning isn’t everything, it’s the only thing.”  This quote, made famous by Vince Lombardi, is a mantra for generations of athletes.  This attitude permeates all sports, even at the youngest level.  If you watch Esquire Network’s “Friday Night Tykes,” you’ll understand how intensified kid sports and sport-related injuries have become commonplace.  You’ll see football coaches yell at children like they’re college phenoms, and then watch the kids get seriously hurt.

Every year, more than 3.5 million children under age 15 require treatment for sports injuries.  This evolution from mere games to full-on quests to turn kids into tomorrow’s superstars has caused a rise in injuries.  What are the perils of youth sports today, and how can we avoid sports-related Emergency Department visits?  One peril is concussions, particularly when kids are charging at each other with extra zeal.

Bailey was a 14 year-old soccer player.  In one tight game she came head-to-head with not another player, but her greatest opponent, the ball itself.  She took her eye off of it for a split second and it struck her in the forehead.  As she lay on the ground, all she remembered was the brightness of the lights and the hush of the crowd.  She tried to stand up but felt too dazed, and began having a headache and nausea.  The coaches were worried she had a concussion, so her parents took her to the ER.  Hours later, after a CT scan of her head, she was discharged with instructions to not play or even work out for at least a week.  Intense play resulted in a long time on the DL.

The American Academy of Pediatrics recommends kids who sustain a concussion be evaluated by a doctor before returning to play.  They need “brain rest,” to resolve the symptoms and let their brains heal.  This means physical rest and “cognitive” rest, relieving the thinking part of the brain.  Cognitive exertion, like homework, video games, or school work may worsen headaches, nausea and fatigue, and make them last longer.  Some kids need weeks or months for these to go away.

12 year-old Bradley was at bat.  Bases loaded, bottom of the ninth, he envisioned his  hit sailing over the outfield wall.  Instead he took the pitch to his ring finger.  He missed the post-game festivities, finding himself in the Emergency Department getting x-rays.  The finger was broken.  

Besides broken bones, or concussions like Bailey’s story above, kid sports injuries often happen less dramatically.  While Bailey and Bradley’s mishaps could happen in sports at any level, the intensification at youth level often leads to overuse injuries we used to see only in college or professional athletes.

Take Little League Elbow.  This didn’t exist when I was young, but now happens to kids who throw too much.  It mostly affects pitchers, but anyone who throws baseballs or softballs a lot can get it, stressing the ligament on the inside of the elbow.  The ligament becomes inflamed, swollen, and hurts.  In extreme cases the underlying bone can come apart, or kids can develop arthritis.

To prevent Little League Elbow, everyone’s now aware of the pitch count.  There’s tables to tell how many pitches children are allowed by their age, but coaches need to be careful.  The school coach may hold his pitchers under their counts, but does he factor how many pitches the kids are throwing at private lessons, or with a select team?  The sum of all those should be under the safety number.

Better prevention of overuse injuries, and more fun, is to vary children’s sports.  If a kid loves sports, she should do a variety- soccer one season, running another, baseball another, etc.  Also, parents and coaches need to dial back the intensity.  The science is clear- too much training is more likely to lead to an injury, rather than to a college scholarship. Kids should learn injury prevention skills like hydration, warm-up exercises, warm-down stretches.  They shouldn’t be pressured to play hurt, but instead encouraged to speak up when in pain.  Then they need adequate rest and rehab.

Preserving young athletes’ health is everyone’s responsibility: coaches, teammates, parents, and physicians.  It’s a balance between keeping kids out the ER, and heeding the call to ”Put Me In Coach!”

Concussion- When Can I Go Back In, Coach?

Now that football season is on again, we are seeing a lot of head injuries in the ED.  Usually the concussion is obvious- the player was knocked out, or obviously confused after the hit.  Last week though, I had a player come in for a wrist injury.  Then he told me, “by the way,” that he had had a tackle the night before where afterward, he could not remember plays or even what his own position was!  Now he had a headache- was this a problem?

I asked him why he did not tell his coach about his head injury.  He told me that the coach was “crazy” about kids slacking off and did not want to upset the coach and not be put back into play.  I told this teenager and his mom about the dangers of a second hit while concussed, where brain swelling and even death are real possibilities.  Fortunately for this player, his arm had a minor fracture and his season with this coach and his head injury was over anyway (fortunately, except of course for the broken arm).

Concussions are being recognized by the NFL, the NCAA, LHSAA, and other sports as a big problem.  This year the NFL has much more strict rules about putting players in after a concussion.  Watching last Sunday’s Saints game,  I noticed that after a head injury, players were being given neurological exams on the sidelines.  The Arizona quarterback, Max Hall,  was taken out for a time after a head injury, even though he wasn’t knocked out (he looked pretty dazed though, I’m surprised they let him back in).

What is a concussion?  A concussion is a head injury where you have certain symptoms afterward, like confusion, headache, nausea, poor concentration, and poor coordination.  In the next few days kids with concussions can have sleepiness, depression, and poor school performance.  Repeated concussions can lead to long term problems with thinking ability and mood.  Some people with a career of head injuries, like boxers and pro football players, can have syndromes like Traumatic Encephalopathy, which is akin to early Alzheimer’s disease.  A kid with a second head injury while having concussion symptoms can end up in Intensive Care with serious brain swelling.

As always, prevention is important.  Football equipment needs to be up-to-date.  Players need to be taught to tackle safely, where the player tackles with their arms and shoulders with heads up,  not “spearing’ with their heads.  The new rule is “see what you are hitting.” 

Coaches and trainers need to know to watch for which players might have a concussion, do a quick sideline exam, and take out players with any concussion symptoms, no matter how minor.  No need to take a chance with tragedy!  Finally, players need to return to play only when they are free of concussion symptoms.  Then they need to return to play in a step-wise fashion.  This means that after a week of healing, they return only to running and calisthenics.  If they are still symptom-free, then they can go back to running plays in practice, without contact.  Then if that is okay, they can go back to full contact.

Coaches, families, and players need to be aware of concussion.  Football, soccer, basketball, hockey (ice and field) and baseball and softball players, be careful!  Cheerleaders too- cheering is now considered a full contact sport, what with cheerleaders being stacked and thrown higher and higher into the air, and occasionally dropped back onto the ground.  There is no good reason to take chances with your brain.  I know this is Louisiana and we are talking about football, but again, isn’t it only a game?