Abstract
Background:
Some NCAA conferences now require a press box-based Medical Observer for all football games to identify injuries missed by on-field providers. The objective of this study was to determine whether a Medical Observer identified injuries missed by the on-field medical personnel.
Methods:
This was a comparative observational study of injury identification methods which was done at nine NCAA football games. The athletes on a single institution’s varsity football team participated. Eight games and one bowl game were studied. Observers were sports medicine Fellows (Orthopaedic, Primary Care). Injury logs were kept by the Medical Observer to document game day injuries. The athletic training staff collected injury reports in the days following games. These were compared with game day injury logs to identify any injuries that were not reported to the medical staff during competition.
Results:
A total of 41 game injuries were identified (4.56 injuries/ game). 29 injuries (29/41; 71%) were identified by both the sideline medical providers and the Observer, 12 (12/41; 29%) were identified by only the sideline medical providers and no injuries were identified by only the Observer. A total of 95 game-related injuries were evaluated in the training room on the day after each game. 27 injuries (27/95; 28%) had been identified during the game (9 [33%] by the sideline medical team and 18 [67%] by both the sideline medical team and the Observer). Fourteen game injuries were not severe enough to require care the following day. There were 68 (68/95; 72%) delayed self-reported injuries treated by the training room staff the next day.
Conclusions:
A press box-based Medical Observer did not identify any injuries missed by the on-field medical staff. This study did, however, identify a large number of unreported game-day injuries that were treated the following day.
Level of Evidence: II
Keywords: concussion, football, injury prevention, medical observer, missed injury
Introduction
American football at all levels accounts for over 1.5 million injuries each year.1 These injuries range from minor sprains and strains, torn ligaments and tendons, to more serious conditions such as exertional heat illness, long bone fractures, spine injuries, and concussions.2 Traumatic injuries pose the threat of enduring beyond a player’s athletic career and affecting his or her livelihood down the road through osteoarthritis, neurodegeneration, or depression.3-5
Concussions, for example, may have prolonged consequences for those affected, and have been highlighted recently in both the medical literature and by the media. Concussions make up at least 6.8% of all collegiate football injuries,2 and the true incidence is likely higher due to underreporting.6 Although the specifics of return-to-play protocols are debated,7,8 it is widely agreed that repetitive brain trauma can lead to a number of long-term sequelae.3,9 There has been increasing concern that concussions and other football injuries are being unreported by players or being missed by medical staff during competition, putting players at further risk of long-term complications.6
The University of Florida started a pilot program in 2014 that placed a medical provider in the press box during home games to watch for concussions and other missed injuries. This initiative has been adopted by many conferences but is not standardized to all conferences. The BIG TEN and the Southeastern Conference currently use one independent certified athletic trainer to watch both teams and monitor for head and neck injuries. The Atlantic Coast Conference (ACC) mandated that a Medical Observer (MO) who was a member of the team’s medical staff must be present at all games this season. ACC Commissioner John Swofford mandated that two medical professionals be designated to watch from the press box during every game, with “the sole purpose of observing from on high, if you will, what’s taking place on the field that somebody on the sidelines might not be able to see.”10 We are unaware of any published reports regarding the results of this new initiative at any other institutions.
During the 2015 football season, this role at Duke University was delegated to the Orthopaedic and Primary Care Sports Medicine Fellow Physicians. During home games, a single Orthopaedic Sports Medicine Fellow was assigned the role of the Medical Observer for the entire game, while both an Orthopaedic and a Primary Care Sports Medicine fellow worked the sideline. During away games, one Primary Care and one Orthopaedic Sports Medicine fellow split the responsibilities of sideline and Medical Observer duties, switching at half time. The purpose of this study was to evaluate whether the Medical Observer was able to fulfill the expected duty of identifying injuries missed by the on-field medical personnel. We hypothesized that the Medical Observer would not identify injuries that were missed by the referee, the sideline medical providers, or both or injuries that were unreported by athletes during the game.
Methods
New guidelines from the ACC require teams to provide a Medical Observer in the press box for all home and away games (Figure 1). For the 2015 season, 13 games (12 regular season plus one bowl game) were monitored. The role of this Medical Observer is to report any potentially missed injuries to the team physicians and athletic trainers on the sideline via direct head set communications or dedicated hardwired ring-down phone. This policy was established at the beginning of the football season. A provisional log was developed for the Medical Observer to record any player injuries seen by the Medical Observer, and to record whether the injuries were communicated to the sideline staff. These logs were kept for the first four games of the season, but they failed to designate whether the medical providers on the field already identified the injuries, and thus were not included in our final dataset.
Figure 1.
The medical observer vantage point from the press box.
After institutional review board approval was obtained (after the fourth game), more specific data was collected prospectively to identify the effectiveness of the newly mandated Medical Observer policy within the ACC (Table 1). Specifically, the Medical Observer would document:
Table 1.
Example of Game Day Injury Log
| Date: _________Duke Football vs ____________1st Half Observer:_______________________2nd Half Observer:_____________________ | |||||||
|---|---|---|---|---|---|---|---|
| Quarter | Time on clock | Player number | Player name | Suspected injury area (if known) | Seen by providers NOT by medical observer | Seen by provid- ers AND medical observer | Seen by medical observer but NOT by provider |
Injuries identified by both the sideline medical providers and the Medical Observer. We hypothesized that this would identify the majority of injuries. The Observer would document two scenarios: 1) when the player was injured on the field and the medical provider goes out to the player and 2) when players were obviously injured and made their way to the sideline for care.
Injuries that were identified by the medical providers on the sidelines but NOT by the Medical Observer. This includes subtle injuries that occur during play that were reported by the player to a sideline medical provider after the play or series and asked to be evaluated.
Injuries that were MISSED by sideline medical providers and referees but were IDENTIFIED by the Medical Observer.
After discussion with the medical staff, criteria were set outlining when the Medical Observer would use the head set to communicate to the sideline medical team. Abnormal player behavior (limping, stumbling, etc) was used identify a potential injury. Because the purpose of this study is to evaluate the ability of the Medical Observer to effectively identify missed injuries, injuries were reported by the Medical Observer to the sideline medical team on the following occasions:
There is an injury seen by the Medical Observer, no one else has identified the injury over the radio, and the player is about to line up for participation in the next play.
There is an injury seen by the Medical Observer, no one else has identified the injury over the radio, the player goes to the sideline and does NOT seek medical attention.
To maximize accuracy of data, all sideline medical providers (physicians, athletic trainers, physical therapists, etc.) agreed to state clearly over headset communications each time they identified an injury and when any player reported to them with an injury related complaint. This would allow the Medical Observer to document on the data log that the injury was identified by both sideline medical providers and the Medical Observer, or just by the sideline medical providers. Additionally, a daily injury report was kept by the athletic training staff and updated after each athletic training room session. This was used to identify any injuries from the game that were not reported by a player to the sideline medical staff.
Results
Data were collected using the new data collection form for eight regular season games and one post-season bowl game. During the nine games, 41 injuries (from 38 players) were logged (4.56 injuries per game). Twenty-nine (29/41; 71%) were identified by both the sideline medical providers and the Medical Observer. Twelve injuries (12/41; 29%) were identified by only the sideline medical providers. There were no injuries that were identified by only the Medical Observer.
The game-reported Medical Observer logs were compared to injury reports from the athletic training room on the days following games. A total of 95 game-day injuries were evaluated in the athletic training room the week after each of the nine games. Of the 41 injuries documented in the Medical Observer log on game day, 27 were subsequently seen in injury clinic, while 14 did not need to receive further treatment in the subsequent injury clinic. These numbers are further broken down based on who observed the injuries (Table 2). The other 68 injuries were self-reported in the athletic training room the day following the game in which they were occurred.
Table 2.
Comparisons of Injuries Identified on Game Day and Confirmed at Subsequent Injury Clinic
| Identified on game day | Significant enough for injury clinic | |
|---|---|---|
| Identified by sideline providers ONLY | 12 | 9 (9/12; 75%) |
| Identified by sideline providers AND medical observer | 29 | 18 (18/29; 62%) |
| Identified by medical observer ONLY | 0 | 0 (0/0; 0%) |
| Total | 41 | 27 (27/41; 66%) |
In the athletic training room visits after the game, an injury system was used by the athletic training staff, which stratified injuries as minor, moderate, or significant. Players considered to have “minor” injuries were able to continue with full activities, those graded as “moderate” were limited in practice or were game-time decisions, and those with “significant” injuries were injuries that would preclude them from football activities until further evaluated. Many of these “minor” injuries include injuries such as small strains and contusions. Of the 27 injuries seen by the medical staff during games and subsequently evaluated during injury clinic, eight were considered minor injuries and 19 significant injuries. Of the eight minor injuries, three (3/8; 38%) were identified only by sideline providers, while five (5/8; 62%) were identified by both sideline providers and the Medical Observer. Of the 19 significant injuries, six (6/19; 32%) were seen only by sideline providers, while 13 (13/19; 68%) were seen by both. Fourteen identified injuries from games did not appear on any of the subsequent injury reports, four (4/14; 29%) of which were identified only by sideline providers, and 10 (10/14; 71%) of which were identified by both sideline medical providers and the Medical Observer. Of those fourteen, four injuries occurred during the bowl game and thus players were unable to attend next-day injury clinic, while the other ten were presumed to be insignificant injuries. Of the 95 self-reported injuries the day after the game, 45 were classified as minor, one moderate, and 49 as significant injuries. A comparison of identified game day injuries versus those self-reported in injury clinic is represented in Table 3.
Table 3.
Comparison of Identified Game Day Injuries vs Delayed Self-Reported Injuries
| Injury clinic total injuries | Identified game day | Delayed self-reported | |
|---|---|---|---|
| Mild | 45 | 8 | 37 |
| Moderate | 1 | 0 | 1 |
| Significant | 49 | 19 | 30 |
| Total | 95 | 27 | 68 |
Six players suffered concussions as a result of in-game action; four were reported by both the Medical Observer and sideline staff. One of the unreported concussions occurred on the final play of the game and was evaluated in the locker room immediately following that game. The other was self-reported by the player in the athletic training room the day following the game but was not seen by any staff when it occurred. In addition, one player was evaluated on the sideline due to concern by the Medical Observer for a concussion, but he was deemed not to have a concussion and was allowed to return to the game.
Discussion
Our data through the first season supports our hypothesis that the Medical Observer would not identify injuries missed by the medical staff on the field. The sideline medical providers were much more efficient at identifying injuries than the Medical Observer, who did not identify any “missed” injuries. Even though the Medical Observer position was mandated with good intentions, several questions must be raised about its ability to meaningfully contribute to player health and safety.
Missed injuries in sporting events can lead to significant disability, injury progression, and prolonged rehabilitation time, but the actual incidence of missed injuries, specifically in supervised sporting events, is unknown. We found that 72% (68 of 95 injuries) of players waited to self-report their injuries the day after the game. This was a surprisingly high rate and an unexpected finding of our study. In fact, this may possibly be the most important finding to come out of this study and cannot be understated. At our institution, this has completely validated our next-day injury clinic to evaluate any player who feels injured. In regard to the utility of a Medical Observer, however, the type of injuries that are usually missed has a direct impact on the ability of this Observer to contribute. For example, if the most commonly “missed” injuries are joint sprains and other minor injuries, it is unlikely that immediate treatment will lead to faster recovery.11 Furthermore, most catastrophic injuries and orthopedic injuries needing immediate medical attention will cause players to stay on the ground and stop game play, thus negating the need for the Medical Observer.
Even though our Medical Observers did not identify any “missed” injuries this season, we understand this could change moving forward as more games are observed. As previously discussed, concussions have received an increased amount of attention recently, and are often unreported by players.6 Of the six concussions identified in the 2015 season, four were identified and evaluated at the time of incident, one occurred on the final play of the game and was evaluated in the training room immediately afterwards, and the final incident was self-reported the day after the game because his symptoms did not appear until hours after the game. Missing an early diagnosis of concussion could have significant adverse effects, as it puts the athlete at risk for repeat concussion, prolonged post-concussion syndrome, and, though rare, defuse cerebral swelling.12,13
The main limitation to our Medical Observer experience involves the collection of our data. In determining rates of missed injuries or unreported injuries, we relied on communication from the sideline athletic staff to record injuries not seen by the Medical Observer. While the handheld radios provided a mechanism for two-way communication throughout each game, we speculate that there were likely injuries seen and evaluated by staff on the sideline that were not reported over the radio to the Medical Observer. Therefore, those injuries were not marked in our log as “Seen by provider and NOT MO” potentially leading to a higher rate of late self-reported injuries. This was a known potential weak point in our methods and was addressed early amongst the team’s medical providers. It was understood that all injuries or suspected injuries evaluated on the sidelines would be communicated over the communication devices, however, in the heat of a game, it is unlikely every complaint evaluated on the sideline was communicated to the Medical Observer. In the future, we will develop other ways of capturing this data by asking every player seen in injury clinic if this injury had been reported to anyone during the game or was the player seen by anyone on the sidelines during the game.
Furthermore, regarding collection of data, the decision was made to include subtle injuries reported by the player to the sideline medical provider after the play or series in the “Seen by providers NOT by medical observer” column. While some could argue that these were ultimately “missed” injuries, they were reported by the player acutely and therefore not truly missed in the spirit of this article. With the speed of the game and use of two way handheld communication, it would have been very difficult to differentiate which of these were actually seen by the sideline medical staff and which were player reported. It is important to note; however, that none of these injuries were seen by the Medical Observer. Lastly, in regards to data, as stated in the Methods section, our data set does not include the first four games of the season. Data and logs were kept for the first four games of the season, but they failed to designate whether the medical providers on the field already identified the injuries, and thus were not included in our final dataset.
There are also several limitations to the use of a Medical Observer from the policy level. First, the credentials and role of the Medical Observer vary greatly depending on the conference. The SEC and BIG TEN use certified athletic trainers who are not affiliated with either team and not required at out-of-conference road games. Medical Observers of SEC and BIG TEN games have the authority to stop the game for head and neck injuries, but they are not in contact with the medical staff on the sidelines for other injuries and are not familiar with player injury histories or other ongoing medical issues. Duke University used its own physicians as Medical Observers throughout the 2015 football season at both home and away games, and they had direct communication with the sideline medical staff. Other ACC schools used Medical Observers from their athletic training staff who were not physicians. The ACC‘s model of utilizing members of the players’ care team has the benefit of these providers being aware of the player’s injury history. It could, however, pose potential conflicts of interest and fear of retribution for stopping play that would not likely be present in the SEC and BIG TEN model. Though this concern was not felt to exist during this initial experience, this potentially could pose a problem depending on the environment of the team.
Additionally, the size of the medical staff is different at each school. At home football games, Duke University has 11 medical providers on the sidelines: four certified athletic trainers, one athletic trainer student, two licensed physical therapists, one board certified orthopedic sports medicine physician, one board certified family practice sports medicine physician, and two sports medicine fellow physicians. Other schools may not have as many medical providers on the sidelines and may benefit more by using a Medical Observer than indicated by our results.
The inconsistency of implementation was further noted in the facilities made available to the Medical Observer. Our experience varied greatly depending on the stadium. Many designated positions were outside of a press box with only handheld communications down to the field and no access to any audiovisual support. This contrasted greatly with other locations where Observers were placed inside the press box with access to both live and delayed-feed widescreen video, and/or control of a multi-angle video replay system as well as excellent visualization of the entire field.
The role of the Medical Observer may need to be more clearly defined if there is to be uniformity throughout the NCAA in the future. Forthcoming studies should consider what specific injuries the Medical Observer should be looking for, and should present a list of expected, observable signs that can be seen from the booth. The Medical Observer may also benefit from being assigned a certain group of players or area of the field to watch, i.e., those with the highest occurrence of injuries or those who are least visible to the sideline staff. There is still much to be learned about the potential of the Medical Observer and good reason for these studies to be a priority. It may prove to be well worth the extra position if the Observer can contribute to the safety of players. According to Steve Shaw, the SEC coordinator of football officials, “I think it will be very rare when the Medical Observer takes impact in the game…but in that situation where they might, it could save a player from worse injury or concussion…”14
Acknowledgement
The authors thank for their support and contributions; the Duke Football Athletic Trainers; Suzanne Finley, EMTP; Daniel T. Le, BS.
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