Friday, May 4, 2007

The ball leaves the pitchers’ hand at 94 hours and starts tailing up and in to the right handed batter. Instinctively, the batter turns away and exposes the side of his head just as the ball explodes into his helmet. Welcome to Sammy Sosa’s world this week. After a visit to the hospital he was cleared to play, after doctors determined that he had sustained no concussion or damage to his head. Fortunate for Sammy, but not always the case for weekend warrior and elite athlete alike.

Getting a concussion is a pretty vague term. It runs the spectrum of a minor ding with little consequence to being knocked out for a prolonged period of time. The evaluation and treatment vary depending on the severity of the injury. And sometimes, even the athlete doesn’t recognize that he has been injured. Studies of college football players show that up to 80% of players will sustain a concussion over the course of the season, yet three quarters may not recognize the symptoms.

The brain sits inside the skull surrounded by fluid. It’s capable of tolerating a little sloshing but doesn’t particularly like it. When the skull is hit by something like a fist or a ball or when somebody falls and strikes their head, the brain can bounce around. The more the brain bounces, the more symptoms you get. It’s just like the hard drive of your computer. Jostle it a little, no worries. Drop it a few inches onto a carpet and it may have to be rebooted. Drop it from the second floor balcony and it dies.

The big question for the doc and the patient too, is whether there has been enough force imparted to the skull and brain to cause bleeding. Blood in the brain is not a good thing. It can cause irritability of the brain tissue and stop it from working. It can be irritated enough to cause seizures. The bleeding can expand and press of the brain increasing pressure inside the skull leading to coma and death. All bad things. Fortunately, we can look inside the skull with CT and find the bleeding areas and treat them to minimize damage (Hurrah for neurosurgeons).

But not everybody needs a CT scan or neurosurgeon .Some injuries can be classified as minor and just because the technology is there doesn’t mean it needs to be used. Clinical rules have been developed to decide who would need a scan and who can be sent home safely without one. They apply to the walking wounded; those people who arrive fully awake and have a normal neurologic exam. If there is no evidence of skull fracture, no vomiting, no significant amnesia and the mechanism isn’t high risk, like getting thrown out of a car, then CT scan may not be indicated. (If you’re interested, check out the Canadian CT head rules: http://www.ohri.ca/emerg/docs/cdr_cthead_poster.pdf )

But what about the people who get hit in the head, may have been a little shaken and are now fine? The symptoms of their head injury and concussion may be a little while in surfacing and may be difficult to recognize as being due to the concussion. Difficulty concentrating, irritability, insomnia, problems with bright lights or sounds, nausea and headache seem pretty non- descript, but may be the consequences of a minor head injury. The symptoms can be severe enough to decrease performance at work or school and on the playing field and should not be ignored.

Depending on the severity of the concussion, return to the field of play or the workplace will depend on when the symptoms resolve. For those not going back to battle on the football field, the return to work poses little risk. But for those returning to contact sports, the brain needs to be completely healed before being exposed to potential new injury.

This week the NFL announced that it will make baseline neuopsychologic testing mandatory this year for al players. They will be tested for memory, motor skills and cognition skills. Should a player sustain a concussion, there will be a way to measure whether brain function has been affected and will allow better return-to-play decisions.

In effect, these elite athletes become guinea pigs for the rest of the world. The sports medicine world experiments on these players. Teams who invest millions of dollars in their performance, want them back in the game as soon as possible. What is learned in diagnosis, surgery and physical therapy become the standards for the general public. So when we cheer respectfully for an injured athlete as he comes off the field, perhaps we’re cheering for more than we know.

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