New Head Space

Posted on 20 September 2019

When Patrick Lambie announced his retirement from rugby at the age of 28, many fans were left confused: how could symptoms of concussion cut a whole career short?

As Mediclinic and ER24 event experts explain, not all head injuries are the same – and our strategy to prevent and treat them is evolving.

Most people watching a game of rugby are off duty. On the couch, in the stands, having a good time. Not Lenise van der Westhuizen. “When we are on the side of the field you may think we’re there to watch the match for the fun of it. But we don’t watch the game. We watch the players,” says the ER24 Intermediate Life Support Paramedic and ER24 Event Co-ordinator: Western Cape.

We have to be vigilant to spot a wide variety of injuries. So when we saw Pat get hit like that, we knew it was serious. The game carried on. But we were already moving.”

Newlands Rugby Stadium, Cape Town, June 2016: Patrick Lambie receives the ball just inside his own half and looks to put his wing, Lwazi Mvovo, into space. He chips the ball over Ireland prop CJ Stander, who jumps to charge the ball down. The players connect – head versus hip. Mvovo does well to collect the ball and recycle it quickly to the right of the field. By now the Springboks are in a promising attacking position, with the Irish defence scrambling.

In the heat of the moment it takes a few minutes for anyone – the crowd, the rest of the players, even the referees – to notice that Lambie has stayed down. But Van Der Westhuizen, together with the rest of her field-side medical assistance team, is already on the field, huddled around the flyhalf as they work to stabilise his head and neck. Eventually, after reviewing slow-motion replays, the referee is moved to issue a red card, expelling Stander from the field. The game goes on. For everyone except Lambie.

“An incident like that, we won’t hesitate,” says Van Der Westhuizen. “Getting onto the field, supporting the team doctor, removing the player from the field as fast as possible – that’s our goal.”

For Lambie, that blow to the head was just the start of what would become a recurring series of concussion-related incidents. When he retired from all forms of rugby in January 2019, he opened up about the pressure that comes with being “in combat mode”: taking hits, and hiding the effects, for the sake of the team. “I had promised myself when I’d had previous head injuries that I would never run onto the field without feeling 100%,” he told The Times. “But I didn’t want to let the club down. I’d just arrived, I was part of a special team. I’d already spent seven weeks on the sidelines because of a head injury. Now it was crunch time.”

Clinically speaking, concussion is a type of traumatic brain injury that disrupts the normal functioning of the brain, explains Dr Daniel Fiendiero, an emergency medicine specialist at the Level 2-accredited Trauma Centre at Mediclinic Pietermaritzburg. “This is something that is often misunderstood: it is an injury to the brain that causes it to behave abnormally.”

 

SYMPTOMS OF CONCUSSION CAN RANGE WIDELY FROM PERSON TO PERSON, DEPENDING ON THE NATURE AND EXTENT OF THE INJURY.

 

Headaches are common, along with a feeling of pressure in the head. Players may temporarily lose consciousness, or, if they remain awake, experience confusion, dizziness and amnesia. They may struggle to stand upright, slur their words, or become nauseous, and begin vomiting. Many cases of concussion are missed by coaches, spectators and bystanders because symptoms of this condition are most evident when an affected player is forced to use his injured brain, says Dr Fiendiero. “Someone might come in on a Saturday after a game, looking a little dazed and confused, and we’ll assess him, treat him as best we can, and send him home. But by Monday, he’s back at school, and suddenly he’s falling over, throwing up non-stop.”

In the long term, those effects can develop further, into speech and sight issues, sensitivity to light, chronic migraines, and mood disorders, including depression and changes in personality. Critically, they can linger, lasting anything from a few days to a season, an entire career – or a lifetime. This is a real danger when players experience recurring concussions, says Dr Fiendiero.

“A player who has been concussed might have trouble concentrating in class – that’s it. He may feel it’s safe to play again, but his balance and coordination are compromised. He is so much more likely to become injured again. That cycle of playing without allowing enough time to heal, puts the health of your brain at risk.” What motivates most players who present with head injuries, he says, is a desire to get back on the field. This becomes an ethical problem, says Dr Fiendiero. “You’ve got a player with impaired brain function who wants to keep on playing. Is it right to expect him to make the best decision?”

Lambie explains how one particularly big tackle, in a particularly important game, left him dazed but determined to play on. “It was a big collision. I stayed at the bottom of the ruck, feeling dizzy. Everything was spinning. I tried to get up, sort of wobbled a bit, went back down for the rest of the passage of play. I had some ice on my head, sprayed myself with some  water, shook it off. I said I was fine and carried on.”
That was a mistake.

 

“I STILL WAKE UP WITH A THROBBING HEAD, LIKE SOMEONE’S WHACKED
YOU ON THE HEAD WITH A BASEBALL BAT. I TRIED TO IGNORE IT. I TRIED TO PRETEND THAT I WAS FINE. I WAS TRYING TO LIE TO MYSELF.”

 

Perhaps unsurprisingly in a sport that revolves around frequent collisions, concussion in rugby is common. To put this in perspective, a 2007 Journal of Athletic Training study estimated that these kinds of head injuries occur in soccer matches at an injury rate of 0.28 per 1 000 athletic exposures. In rugby, that incidence rate is 13 times higher. This shows that of all sports, rugby puts a player’s head at unique risk. To compound the issue, all players are in danger of sustaining head injuries at any time: a recent study by the International Rugby Board of the 2015-16 Premiership season by the Rugby Football Union in England showed that while concussions accounted for 20% of all injuries to the ball carrier, they made up almost half of all injuries to the tackler. The real problem: a high number of concussions are never picked up, and never reported.

An innovative national rugby safety programme aims to change that. BokSmart, which is overseen by Dr Wayne Viljoen, Senior Manager for Rugby Safety at SA Rugby, focuses on educating coaches and referees across all levels of the game in SA, with one goal: to make rugby a safer game for all who play it. Part of the BokSmart programme is the Spineline, a 24-hour, toll-free number, operated by ER24’s team of emergency resource operators, explains Dr Robyn Holgate, Chief Medical Officer: ER24 Clinical Department. “This is a dedicated emergency helpline, designed solely to provide the best, most appropriate and fastest pre-hospital emergency medical care to treat potential serious concussion, head, neck and spine injuries sustained while playing rugby,” she says.

ER24 provides more than just access to expert care over the phone, Dr Holgate says: ER24 paramedics provide fieldside medical assistance teams at rugby matches in SA, from high-school games to Super Rugby, Sevens and internationals. These medics, Lenise van der Westhuizen included, are trained in World Rugby-approved, evidence-based BokSmart safety protocols to ensure they identify serious injuries and take immediate, appropriate action. These measures take the decision-making process out of the affected player’s hands and place full responsibility on the spectators, players and referees around them.

As the preferred medical assistance provider to the Toyota Cheetahs, DHL Stormers, Vodacom Blue Bulls and Cell C Sharks, ER24 and Mediclinic personnel play a central role in that process, providing field-side emergency medical services for players at all games hosted at these venues, across all age groups. And as the official medical assistance service provider for the high-profile HSBC World Rugby Sevens tournament in Cape Town, Mediclinic provides trained nurses, doctors and a fully-equipped field hospital to ensure players at the event get the best possible treatment when required.

“Concussion, head injury and spinal injuries are of course a major focus for us, as they can be serious and may be difficult to identify immediately,” says Dr Holgate. “How we respond in that moment can have a lasting effect on that player’s wellbeing, so we have to be trained and ready to treat them properly.”

What does concussion treatment look like?

Dr Darren Green, Manager: Mediclinic Events Department, says his team’s best-practice guidelines to treat head and spinal injuries in rugby revolve around three fundamental principles: recognition, removal from play and full recovery.

“Head injuries are incredibly complex,” he explains. “Sometimes they can be easy to spot, and it’s clear in the moment that something is drastically wrong, but sometimes these injuries are more subtle, and you’ll only see the effects a few minutes later, once the game has moved on.”

In these cases, it helps to watch the game from multiple angles. “At any one time we have six pairs of eyes on the field,” he says. “I’ve got paramedics, each team’s doctor and physiotherapist, a match-day doctor, two experts watching a live video feed, and then there’s the referee. If we see a big collision, or we suspect a player may be concussed, our main aim is to get onto the field to assist the team doctor quickly, to stabilise and diagnose them and start treatment as soon as possible.”

Dr Green says he appreciates the responsibility that comes with safeguarding young lives. “I like to tell these players, I’m not here to get you through this rugby match. I’m in charge of your entire rugby career, from a medical perspective. I’m here to protect you, and to ensure you enjoy this game, and your life outside this sport as well, for as long as possible.”

 

A HIGH NUMBER OF CONCUSSIONS ARE NEVER PICKED UP, AND NEVER REPORTED.

 

RECOGNISE the signs and symptoms of a potential concussion.
REMOVE the player immediately if you recognise any signs and symptoms, and suspect a concussion.
REFER the player to a medical doctor for a thorough clinical assessment.
REST the player completely until they are totally sign- and symptom-free, and off any medication that might mask the symptoms of concussion. Use the minimum stand-down periods for each age-group category, before entering the graduated return-to-play process.
▶ Full RECOVERY from signs and symptoms is mandated before entering into the age-appropriate graduated return to-play protocol.
▶ To RETURN TO PLAY safely following a concussion or suspected concussion, the players must be sign and symptom free, medically cleared by a doctor to do so, and complete the age-appropriate return-to-play protocol. For the purpose of concussion, full contact practice equals return to play

SIGNS OF CONCUSSION?

QUESTIONS TO ASK PLAYERS 13 AND OLDER
▶ What venue are we at?
▶ What team are you playing?
▶ What half is it?
▶ Who scored last in this game?
▶ Who did you play last week/ game?
▶ Did your team win the last game?

QUESTIONS TO ASSESS PLAYERS AGED 5-12
▶ Where are we now?
▶ Is it before or after lunch?
▶ What did you have last lesson/ class?
▶ Who scored last in this game?
▶ What is your teacher’s/ coach’s name?

 

WORDS THOMAS OKES
PHOTOGRAPHS WARREN VAN RENSBURG

In the interest of our patients, in accordance with SA law and our commitment to expertise, Mediclinic cannot subscribe to the practice of online diagnosis. Please consult a medical professional for specific medical advice. If you have any major concerns, please see your doctor for an assessment. If you have any cause for concern, your GP will be able to direct you to the appropriate specialists.

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