caffeine, concussion, compartment syndrome

Saturday, May 20, 2017

With every news report, opportunity lurks to learn about the underlying story, if only the writer or broadcaster would take a few minutes to explain. When the story is about medicine, it’s also most important to make certain that the facts confirm the situation. It’s no different than at the bedside, when the patient’s history has to make sense with the doctor’s diagnosis.

A couple parables drawn from the week’s news and a reminder and caveat that it is dangerous to practice medicine from press clips.

Caffeine

A sad story of a 16-year-old who had sudden death, collapsing at school. As reported by Lauren Sausser of the Charleston courier and Post, the autopsy was normal, including a normal heart. The coroner declared the death due to caffeine overdose, even though the toxicology report measured the serum caffeine level at 1.1 micrograms per deciliter and most toxicology references list the average lethal dose at 120 micrograms.

The Richland County coroner…acknowledged during an interview with The Post and Courier that this amount of caffeine shouldn’t have killed the Midlands teenager…case is controversial because some medical experts have doubted his conclusion. “They can talk to their experts. I’m going to use mine,” he said. He agreed the teenager’s death is “highly unusual,” but insisted his office “exhausted any other possibility.”

The story went viral making national and international headlines. The American Academy of Pediatrics reminded parents that caffeine is recommended for children. But the real story is that sudden death occurs when an abnormal rhythm, usually ventricular fibrillation or ventricular tachycardia, prevents the heart from squeezing in a coordinated way and not allowing blood to be pumped through the body. The only effective treatment is electricity, shocking the heart back into a normal rhythm, and it is why AEDs (automatic external defibrillators) need to be easily found in public spaces.

Sadly, a coroner decides he can’t find another cause of death, so he makes one up. If he had admitted that no cause was found other than unexplained sudden death, then the viral story might have talked about bystander CPR and AEDs.

Concussion

The NFL and NHL are under siege when it comes to concussion diagnosis, treatment and prevention. Though it’s off season for football, Gisele Bundchen made news when she revealed that her husband, Patriots quarterback Tom Brady, had sustained a concussion in the past season. From the injury record, and reiterated by the NFL, there was no report of Brady suffering a concussion. Bundchen’s loyalty to her husband’s career was questioned. Why would she leak such a secretive story? And why didn’t the team or the league know that he had had a concussion?

The diagnosis of concussion is not easy, Symptoms may be subtle and delayed and perhaps only recognized well after the game where the injury occurred. It may be family that recognizes changes in personality with irritability or a change in sleep pattern, either insomnia or excessive sleepiness. The consensus statement of the most recent conference on sports related concussion held in Berlin in 2016 noted the following:

There is no perfect diagnostic test or marker that clinicians can rely on for an immediate diagnosis of SRC (sport related concussion) in the sporting environment.

The storyline should have focused on the need for family members and friends to be the extended nursing providers who can detect symptoms after a head injury, whether it occurred at work, riding a bike or playing in the park. Those who know the victim well are in the best position to observe changes in personality and function.

Emergency Surgery

 

Ryan Johansen underwent emergency surgery after hurting his thigh in the Nashville Predator playoff game. The NHL chooses only to release vague injury reports and it is up to the reader to guess what might be going on.

Emergency surgery is a big deal and there are few time when a patient needs to be rushed to the operating room. A few examples include:

  • Major trauma with internal bleeding and a patient who is so unstable and in shock that there is no time to wait for less invasive treatments
  • Bleeding in the brain with increased pressure in the skull (increased intracranial pressure) so that the blood clot has to be removed and the bleeding control to prevent further brain damage
  • An arterial blood clot that stops blood supply to an arm, leg or intestine. Timing of the essence to restore the blood supply, otherwise tissue quickly begins to die.

Otherwise, there may be an urgency to operate ,but surgery can be delayed until the patient’s condition has been optimized to minimize complicat8iosn from the operation or the anesthesia.

For Johansen, not a lot of emergencies exist in the thigh. Broken bones don’t need emergency treatment unless there is an open fracture, the skin overlying the fracture is torn and there is a risk of infection. Torn ligaments or tendons don’t need emergency repair. But perhaps it was compartment syndrome. In the thigh and other places within the body, muscles are contained in compartments with tight bands of tissue surrounding them. If the muscle is damaged and swells or bleeds excessively, the pressure within the compartment can rise. If it increases enough, blood flow through the area is compromised and muscle can die.

The treatment is emergency fasciotomy, where the compartment tissue is fileted open to allow the muscle to expand. This is an unusual injury but a good lesson for the public to know that keeping injuries iced and elevated can help prevent swelling and its complication.

Three stories, three lessons. Three opportunities for a parable to teach lost. And a reminder that one should not practice medicine based on newspaper, internet and television reports.

 

 

 

 

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concussions and football

Tuesday, September 30, 2014

 

The latest concussion controversy involves Shane Morris, the University of Michigan quarterback  whose head injury was unrecognized by the coaching and medical staff on the sideline and therefore was allowed to continue to play. After a few public relation gaffs, the university admitted that an error was made and instituted new procedures to address the “communication processes”. Athletic director, Dave Brandon, said that Michigan would have an athletic medical professional in the press box or video booth with the ability to talk to the medical personnel on the field and would increase communication between medical and coaching staff as to player availability.

The NCAA has a recently revised policy on concussion that addresses the issues of diagnosis, treatment and return to play. Good for the NCAA and good for Michigan but it is just window dressing for the whole head injury issue. Here are but a few of the issues that make head injuries a significant public health issue.

There is no easy way to make the diagnosis: Depending upon the research you choose to read, somewhere between 30 and 50 percent of head injuries go unrecognized and therefore unreported. The NCAA guidelines suggest that players will hide their concussion because of the invincibility of youth to fear of losing their roster spot. Studies looking at concussion rates in high school and college athletes suggest that the player did not report concussions because they were unaware that their symptoms were associated with head injury. Headache was the most commonly non-reported initial symptom. Those who had an unreported concussion were more likely to be knocked unconscious with a subsequent concussion and also have more severe post-concussion symptoms.

The diagnosis on the field needs to rely on the players and referees on the field: It is nice that Michigan has the resources to place medical personnel in the press box and have communications equipment to talk to the medical and coaching staff on the field. For all the football played in the US, from freshman and JV high school games to the Division II and III college level, virtually none will have a neurologist or head trauma specialist on the field or in the press box. Most won’t have a press box. Coaches on the sideline are too often shielded from all the action and it’s incumbent upon those on the field to be their brother’s keepers. Watching the replay of Shane Morris laying on the field after being hit, slowly getting up, stumbling and having to be supported by another player, it is clear that something is wrong. Yet, after a few seconds, he waves off help and gets into the huddle for the next play. The lineman who helped steady him and the referees on the field need to feel empowered to stop the play and have him removed.

The diagnosis of concussion on the sideline, in the ER or the doctor’s office may be also difficult to make: While it is easy to make the diagnosis of head injury when a player is knocked unconscious, is vomiting on the field or is dazed and having light sensitivity, many of the symptoms can be subtle and take hours to manifest themselves. It could be that irritability, difficulty concentrating, changing sleep patterns or headaches lead to the diagnosis. While guidelines and scoring systems exist, the diagnosis of concussion is made clinically by symptoms alone. By definition, a minor head injury or concussion, may have a normal physical exam.

Treatment of concussion is brain rest, but for how long: The first order of business is to remove the player of the game to prevent further injury. In football, that starts by having the medical staff take away the player’s helmet. There is no missed communication between the athletic trainers and coaches when the player walks the sideline without a helmet on his head or in his hand. There is a six step program endorsed by the NCAA and the 2013 Zurich International Conference on Concussion in Sport that lays out the path for an athlete to return to play. It is interesting that while there is a presumed safe path to the football field, there is no such safe path to return to school or work.

From the NCAA: “There are no standardized guidelines for returning the athlete to school…Returning the student to school, even if the day is shortened, can be considered when the student can tolerate cognitive activity or stimulation for approximately 30 to 45 minutes. This arbitrary cutoff is based on the observation that a good amount of learning takes place in 30- to 45-minute increments… Given that most concussions resolve within three weeks of the injury, adjustments may often be made in the classroom setting without formal written plans.”

So it is with a heavy heart that we congratulate the University of Michigan, the NCAA and college football. Players will be watched from on high, yet between one third and one half of concussions will not be recognized. There will be no easy way to make the concussion diagnosis. Rest will be the only treatment available. Return to full play may occur within one week, yet return to the classroom may be limited to less than an hour a day.

With all this lack of clarity, what direction and information does this give to players and to their parents who want their kids to play ball. It’s a reminder that institutions of higher education, like the University of Michigan, have a hard time applying science to their everyday lives.

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