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CASE STUDY: Clearing Athletes for Return to Play
New legislation in Pennsylvania has mandated greater scrutiny of student athletes who suffer on-field concussions.

An interview with Dr. Michael Garfinkel

Dr. Michael Garfinkel recently moved to Sharon, Pennsylvania, to become Sharon Regional’s emergency medicine director. In March, Garfinkel received a call from the hospital’s department of orthopedics/sports medicine, letting him know that they’d developed a protocol to manage head injured students in response to a new Pennsylvania law.

“They came to me to (a) make sure that the emergency care providers knew about the bill, (b) see that our coordinated care plan was in tight conjunction with their aftercare and prehospital care plan, and (c) make sure we were compliant with the bill,” says Garfinkel.

The crux of the new guidelines, according to Garfinkel, is that now, “if there is any concern by a physician, coach or other official, [the student] has to be removed immediately, and cannot be returned until they are cleared in writing by an appropriate medical professional.” While there are many finer details to the law – and similar laws are cropping up around the country – the simple mandate to increase scrutiny on concussion management is a welcome and dramatic shift, says Garfinkel
“The management of concussions has been a moving target for the past decade or two,” says Garfinkel, “If you take a cross-section of how emergency physicians are treating concussion patients nationwide, there is probably extreme variability.” The old neurology guidelines that we were going by, he adds, had physicians – both on the field and in the hospital – giving student athletes a cursory clearance and sending them back to play in the same game where they’d been initially injured. The problem with this is that physicians still have a lot to learn about the extent and timing of concussions. “There may be a patient who is asymptomatic during the emergency department visit, and then a day or two later, starts having trouble concentrating, is dizzy and has headaches. They might seem fine when they’re sitting down, but symptoms will return when the student engages in a range of activities, physical and cognitive.”

Stricter “return-to-play” guidelines also help manage expectations for students and families, who often push physicians to clear their child for an upcoming competition. “There is pressure from parents and from students,” says Garfinkel, “but we just have to stay firm to what we know is good medicine.”

First Steps:
For Garfinkel’s group, the change has been relatively straight-forward. “We had to alter our discharge instructions to add that information under the concussion diagnosis and the follow-up information, and I had to get the word to my docs that we’re not clearing them to play, but coordinating follow-up care.” Where it got slightly more complicated, he adds, is that getting cleared is about more than sports now. New protocols are paying attention to the potential role that cognitive stimulation – such as homework or exams – can play in neurological injuries following a concussion.

If your emergency department is not affiliated with a large hospital system, or a sports medicine department, you should still work on establishing appropriate follow-up protocols in your institution that include subsequent evaluations, perhaps with a neuropsychologist who specializes in head injuries. Learn about the entities that are providing schools with imPACT neurocognitive testing and see how your department can collaborate to improve follow-up care.

In the end, says Garfinkel, it’s pretty simple: “It’s all about coordination of care and managing expectations.” And if emergency department step up, they have a unique opportunity to lead in an area that will have a tangible impact on quality of care.


References:

  • McCrory, P, Meeuwisse W, Johnston, K, et al. Consensus Statement on Concussion in Sport 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Clin Journal of Sports Medicine. 2009; 19:185-200
  • Bazarian JJ, Atabaki S. Predicting post concussion syndrome after minor traumatic brain injury. Acad Emerg Med. 2001; 8:788-95
  • Concussion Legislation by State. (February 2012). Retrieved March 23, 2012, from http://nflhealthandsafety.com/zackery-lystedt-law/states 
 

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