concussion: looking out for those who are injured

Monday, November 13, 2017

As the NFL again takes flak this week for its head injury awareness with potential injuries to the Seahawks’ Russell Wilson, the Colts’ Jacoby Brissett and the Falcons’ Devonta Freeman, it’s important to remember that concussion symptoms can be subtle and have a delayed onset. The concept that a brief assessment on the sideline is sufficient to say yeah or nay on the diagnosis fails to meet the criteria set in the most recent consensus statemen from the 5th international conference on concussion in sport, held in Berlin in late 2016.

The bottom line for initial assessment is that all athletes, regardless on level of competition, should be removed from the field of play, if concussion is suspected. If the diagnosis is not in doubt, for example a player who is knocked out, briefly confused or has difficulty with balance, the player should not return to the game. If the diagnosis isn’t confirmed but suspicion exists, then the player needs to undergo sideline testing. But there is not one perfect test that can confirm or deny the diagnosis. Sideline screening can be done but it takes at least 10 minutes for most testing to be completed. While it can occur on the sideline, it is often better to find a quiet place to interview and examine the potentially injured player.

From the consensus guidelines:

“In cases where the physician may have been concerned about a possible concussion, but after the sideline assessment (including additional information from the athlete, the assessment itself and/or inspection of videotape of the incident) concussion is no longer suspected, then the physician can determine the disposition and timing of return to play for that athlete.”

And also from the same guidelines, an athlete with a sport related concussion should not be allowed to return to play on the day of injury.

There is a caveat that symptoms may be delayed and repeated evaluations are warranted. The problem is that the symptoms can be very subtle, from difficulty concentrating, to sleep disturbances, to changes in personality. The ability for the brain to function and process information may be affected so that concussed high school and college athletes may drop a full grade point in their classes for the ensuing semester.

As hard as it is to diagnose subtle head injury, it’s just as hard to decide when the brain has healed enough to allow the athlete to return to play. There is no test that confirms brain healing and most athletes recover within a month. Practically, return to play strategies take about a week if the athlete remains symptom free. That said, concussion symptoms may last for months.

Unfortunately for those who decide whether a Seahawk or Colt or Falcon can return to play, instant replay allows fans at home and in the stadium to witness the consequences of a hit to the head and judge for themselves whether the possibility of a concussion might exist. And when a referee sends a player off because of concussion concern, it’s incumbent upon the team’s medical staff to follow through with a thorough assessment. The player may not know what happened or realize that they were concussed; it’s up to the coaching and medical staff to protect the brain, even if the player actively refuses that help.

Until that is the standard of care, the NFL will continue to get flak.

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narcotics role is changing

Monday, August 29, 2016

Football is a violent sport and with it comes injury and that begets pain. Some injuries are self-evident, like the tibia and fibula fracture sustained by Chicago Bears quarterback, Connor Shaw. His leg was splinted and he was carted off the field in obvious pain. Other injuries take some time to sort out, like the Cowboys’ Tony Romo, who failed to talk his way into playing in the same game and was later found to have a compression fracture of his lumbar spine. Both injuries hurt and both players will likely be prescribed narcotic pain medication in the first few days of recovery. NFL players have been known to take a variety of legal and illicit medications to allow them to play through the pain each weekend, but that mindset does not translate well into the real world off the playing field.

The Fifth Vital Sign

Not too long ago, pain was added to the medical mind frame as the fifth vital sign. It followed blood pressure, pulse respiratory rate and temperature. Regardless of the reason for the doctor’s visit, patients were often asked whether they were having pain and their assessment, often on a scale of zero to ten. Kids had the smiley/ frowny face pain scale option. Pain is not normal and medicine is all about keeping vital signs in their normal range. Patients didn’t want to hurt and it was easy for a doctor to write a prescription for narcotics.

Doctors like to make their patients feel better but there was another benefit to writing the prescription. Patient satisfaction scores for doctor performance might have been tied to giving patients what they want. Who knew that excessive narcotic prescribing habits might lead to an increase in drug dependence, addiction and become a gateway to the increase abuse of heroin and other illegal street drugs.

The pendulum is beginning to swing back and patients might take a while to understand that a pain-free life may not be available through the use of narcotics. They may not like the doctor who says no to their request and those negative feelings are being expressed by examples of falling patient satisfaction scores.

Wisconsin Prescribing Guidelines

The Wisconsin Medical Examining Board, the governing agency that licenses doctors in the state) has published guidelines about prescribing narcotics, including when to use them what drug to prescribe, how many pills and the expectation to look for patients who exhibit drug seeking behavior. Doctors in the state need to listen and act according. Without a medical license, their career has effectively ended. Just a few of the highlights:

  • It is difficult to know how much a patient hurts. Find out why there is pain and treat the underlying cause. Use non-opioid (non-narcotic) medicines like acetaminophen, ibuprofen or naproxen.
  • If prescribing narcotics, use the lowest dose and fewest number of pills. Most patients will need less than three days of treatment and rarely more than five.
  • There is little evidence that narcotics should be used to treat chronic pain.
  • “Physicians should avoid using intravenous or intramuscular opioid injections for patients with exacerbations of chronic non-cancer pain in the emergency department or urgent care setting.
  • Physicians are encouraged to check Wisconsin Prescription Drug Monitoring Program website to see whether the patient is already receiving narcotics from other doctors. This becomes law in April, 2017 before prescribing any controlled substance for greater than a three-day supply.
  • “The use of oxycodone is discouraged.”

Patient Satisfaction

Patients may not be satisfied with the result of their doctor visit if expectations for pain control are not met. This might be especially true for chronic pain patients who have come to rely on narcotics for their symptom control. It may take time to consider treatment alternatives and still meet the needs and demands of the patient.

The New York Times reported on the experience at Marion (Indiana) General Hospital. Over the course of 18 months, emergency physicians decreased their narcotic prescribing by 50%. Patients weren’t happy and ER satisfaction scores fell from the 58th percentile (of 1100 similar hospitals) to the 14th. Does that mean that the doctors practiced bad medicine or did it mean that there was a disconnect between what the patient wanted and what they received. The words of Mick Jagger and Keith Richards might have been ahead of their time describing this phenomenon.

You can’t always get what you want…you get what you need.

 

 

 

 

 

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