Podcast 26 and 27 – Concussion in Sport with Prof David Hughes (AIS)



David Hughes is a sports physician. He's a professor too. And he got together with two of his colleagues, Lisa Elkington and Silvia Manzanero, to sift through the joint consensus statement on concussion in sport that went through its most recent update in Berlin in 2016 and come up with a position statement on concussion in sport for Australia. The position statement was a collaboration between the Australian Institute of Sport (AIS) and the Australian Medical Association (AMA); so this is big stuff. 

The three authors thought a bit more about it and penned an update to the AIS-AMA position statement on concussion in sport and published it in the Medical Journal of Australia in April. I read it. And I quite liked it because it not only outlined the what of concussion management but also the how and why.

This is really important because there is a lot of back and forth discussion about how to implement the various concussion management guidelines and it can often seem like only professional sports people with the backing of a full team will be able to access the resources needed to effect a safe return to competitive sport.
Not so.

In fact it is all quite achievable.

It is also good to read their acknowledgement and addressing of some of the concerns that many clinicians and clinical support professionals have about some of the diagnostic and therapeutic modalities for concussion.

So it seemed a good idea to track these authors down and put them on the podcast. I managed to get hold of Prof Hughes, in between busy lectures, clinical appointments and academic commitments.



Now go and read the 2016 joint consensus statement on concussion: http://bjsm.bmj.com/content/51/11/838 

Then go and read the update article. It's here: https://www.mja.com.au/journal/2018/208/6/update-ais-ama-position-statement-concussion-sport

Now you are ready for the podcast. Actually, it's two podcasts, as despite only tackling about three-quarters of the material, we still went for over an hour and after editing I've had to split it into two episodes for ease of downloading.

Here are the key items that we address....
1) Who makes up this expert panel that issues the joint consensus statement every couple of years? It's quite a broad range, drawn largely from contact and field sports. There's no motorsport representation, but then there is no representative for snooker either and to date we haven't generated much hard data to get ourselves invited to the party.

2) Why are we hearing more and more about concussion over the past 6 years or so? Are we unmasking it by fixing other problems or have we just admitted its presence and started to look at it properly?

3) There seems to be pathophysiological differences in the manifestation of concussion in men and women, and between adults and children. Women and children take longer to recover, but we don't know why really. This is an evolving area and management guidelines may change as more data is unearthed.

4) Not everyone needs a CT, MRI or formal clinic based neuro-psychological assessment. Thank Christ for that. Triggers to think about referral include:
  • The usual head injury red flags; e.g. Canadian Head CT Rules 
  • Prolonged symptom duration: adults > 14 days, children > 4 weeks; though this may yet evolve further.
  • Significant symptom burden
  • Consideration of a prolonged break or a career end because of concussion

5) Trackside tests like SCAT, ImPACT and K-D are good screening tests, though their results should not be used in isolation to determine the presence or absence of concussion. Clinical judgement is part of the process. Knowing the athlete (e.g. team physician) helps. Additionally, it seems that between athlete gaming, ceiling effects and a degradation in utility over only 3 to 5 days (for SCAT anyway), it is not yet recommended practice to use these tests to determine fitness to return to sport. This is interesting as this does happen around the world and it may also have impact upon some of the studies that are being run to determine the validity of a variety of diagnostic modalities.

6) There are biomarkers of brain injury. They are not yet ready for real time clinical use. They've been covered on the Rollcage Medic site here - Concussion biomarkers, the new brain troponins. There may be more up to date information now as this piece was written 4 years ago.

7) There are a handful of devices that are being developed as expertise-independant trackside diagnostic tests, most of which have little or no publicly available peer reviewed evidence to support their widespread adoption yet. I admit that I really hope the iPAS system works out. It does have some evidence behind it though this is not publicly available (personal communication with developer), however a number of its component tests have received FDA approval. The iPAS system is currently undergoing trials through IndyCar in the USA and the MSA-UK with Naomi Deakin and Peter Hutchinson. So, fingers crossed.

8) Second impact syndrome is still very controversial with strong opinions (and little hard evidence) on both sides. It may be a moot issue as David argues that if a concussion episode is managed correctly, we should never see an acute second hit because the competitor should already have been removed and be under clinical supervision.

9) Chronic traumatic encephalopathy. What a hot potato! Still. Decide for yourself about this but make sure you have appraised the available evidence. Maybe the Boston and now also Sydney-based brain bank will be able to shed some light. Here's the JAMA article with the two videos that David mentions in the podcast: Clinicopathological Evaluation of Chronic Traumatic Encephalopathy in Players of American Football

10) Complete physical and cognitive rest for the immediate 24 hours after a concussion is no longer recommended. Woo hoo! Try getting anyone to comply with that bit of advice. It is now recommended that deliberate rest for 24 to 48 hours should be the aim, accepting light exertion and cognitive activity that does not worsen the concussion symptom profile. Beyond 48 hours, the evidence does not support complete rest and a graded return to full activity is the main strategy.

11) We didn't get into this in the podcast but a predominance of vestibular features appear to be associated with a more prolonged course and worse outcome and there is increasing focus on using occulo-vestibular retraining exercises in the management of concussion. The keen-eyed among you will spot that this is a key target of the King-Devick and iPAS testing systems, as well as the BESS test component of SCAT

12) What if you do need to sit an athlete down and discuss the future of their chosen professional sport? How does one approach that difficult conversation? There is no hard evidence to guide you, according to David and we are not the sports police, so we can only offer the best advice that we have. For those who do step down permanently, assistance with readjustment to life outside of professional sport will be critical. Watch this SBS panel discussion on "Life after sport": 


Here are the podcasts with David

Here's Part I - Concussion and its assessment


Here's Part II - Consequences of concussion and concussion management: 



Attribution: The intro sound clip is the opening bars from Soundgarden's track "Head injury" from their 2017 re-issued album "Ultramega OK". The outro is my own recording of a rally car starting a stage of the National Capital Rally of Canberra in NSW, Australia.

References and resources
Dario Franchitti's videos on retiring from motorsport due to concussion

Podcast 25 – Crew Resource Management in Motorsport Rescue and Safety – David Hakim



David Hakim is an anaesthetist (anesthesiologist) who lives, works and chases race cars in Canada. He gave one of the talks at last year's ICMS annual general congress in Indianapolis. The topic he chose was one that he has spent some time exploring in order to try to streamline how motorsport rescue and safety is practiced by the team that he works with. 

This exploration led him to learning more about how we think and behave in certain situations and, more importantly, what we can do about it to get the best outcomes.

Here's a breakdown of what we get into. It isn't everything that you need to know, so check out the references at the end for further reading.

1) What is Crew Resource Management?

There are several varieties of definition, but essentially it boils down to developing ways of doing things (processes, procedures, strategies) that minimise error potential and enhance the capacity for the individuals involved to best use their knowledge, skills and immediately available resources to achieve the best outcome possible for the situation.

It originated from the aeronautical industry as a way of trying to understand why crashes and mishaps occurred and then identifying strategies to prevent their recurrence. A lot of the language and characteristics of the CRM process have been ported over to various areas of medicine, with a number of groups and individuals working to figure out how best to apply these lessons to patient care.

Crew Resource Management (CRM) is also known by several different names including Crisis Resource Management and Cockpit Resource Management. However, direct extrapolation from aeronautics to another industry is not always valid and there often needs to be some tailoring of practice. So the term is often altered to fit and in motorsport medicine, it has been called Race Resource Management.

Regardless of the name, the key element of CRM is careful analysis of processes to identify the strengths and weaknesses leading to the developments of a strategy that promotes the best outcome followed by ongoing assessment to ensure that the target outcomes are being achieved and evolving as new information comes to light. It is an organic process.

2) Why should we care about CRM?

In general, when things are going smoothly, the stress levels are low and we feel like we are on top of our game. However, that time that we are really tested is when things are deviating from the intended trajectory. This is when a situation can feel like either a challenge or a threat, depending upon whether we feel that we have the requisite knowledge, skills and ability to deal with it. If any of these three components fail, the chance of error and therefore a bad outcome rises.



3) Knowledge and skills

These two components are what we spend most of our time and effort trying to improve. So if we are smart and have the right skills, why should anything go wrong? 

When we are calm, it is fairly easy to assess the situation, choose the correct course of action and act. In a crisis, the pressure is up and something akin to the fight or flight reflex may kick in. If we are not thinking straight, our approach to the issues confronting us may become unbalanced, leading us to apply our knowledge and skills inadequately or inappropriately or not at all.



Both System I and System II processes are useful and have their benefits and downsides. Understanding how they work and how we work with them can help us to refine how we behave when the pressure is on.

"Use your attention wisely"

4) Situational awareness

Simply put, this is our ability to remain aware of or environment and how it might evolve. 

A football player will be aware of roughly where their team mates and opponents are, how the ball is moving, the direction of play and where the goal is. Similarly, for a race track incident, there may be any number of items to remain aware of, such as the location of the incident, whether the yellow flags or safety car are deployed, is the car on fire, where are the rest of the race cars, what are the clinical priorities and whether it's more appropriate to go to the circuit medical centre or straight to the receiving trauma hospital. 

Under pressure, there is the potential to develop tunnel vision, either cognitively or literally. This can be due to:
  • Cognitive overload
  • Environmental overload
  • Communication overload
The result is becoming overwhelmed, which may lead us to being unable to effectively or appropriately apply our knowledge and skills.


5) Resolution

Cognitive and behavioural psychology

Understanding the concepts behind how we think and behave helps us to develop strategies to mitigate the error prone elements. There are multiple resource available to delve in here. Go check out the reference list below.

Cognitive off-loading
  • Pre-event planning and Standard Operating Procedures (SOPs) - How will we approach an incident? Role allocation. Exit strategy.
  • Checklists - These help to reduce the cognitive burden of certain activities, but they need care in their development. Go listen to this podcast: "Checklists" on Phemcast - https://phemcast.co.uk/2018/02/09/episode-27-checklists/
  • Rally points - Regular planned breaks in activity to perform a self and/or team catch up so that it is clear what the priorities are, what the intended targets are, how to get there and whether they are being reached.
  • Leadership and followership
Stress inoculation practice 
  • Sim training really helps here. 
  • Debriefing is critical and is where most of the learning is made explicit and concrete. 
  • There should be specific, achievable objectives. 
  • Start gently and build up as abilities and confidence grows.
  • Practice should be deliberate. 
  • Mixed team and mixed skill training not only improves knowledge and skills but also improves team cohesiveness.

The podcast



The intro music clip is from Music For Pleasure - The Human Factor (7'' Version)
https://www.youtube.com/watch?v=qT_e_v4K1cA



The slides

(These are the slides from David's talk at the ICMS Congress)

Crisis m anagement final from DavidHakim83

References and resources
Finally, Dr Andy Buck has a whole website devoted to clinical CRM and human factors strategies called Resus Room Management - http://resusroom.mx/

Podcast 25 – Crew Resource Management in Motorsport Rescue and Safety – David Hakim



David Hakim is an anaesthetist (anesthesiologist) who lives, works and chases race cars in Canada. He gave one of the talks at last year's ICMS annual general congress in Indianapolis. The topic he chose was one that he has spent some time exploring in order to try to streamline how motorsport rescue and safety is practiced by the team that he works with. 

This exploration led him to learning more about how we think and behave in certain situations and, more importantly, what we can do about it to get the best outcomes.

Here's a breakdown of what we get into. It isn't everything that you need to know, so check out the references at the end for further reading.

1) What is Crew Resource Management?

There are several varieties of definition, but essentially it boils down to developing ways of doing things (processes, procedures, strategies) that minimise error potential and enhance the capacity for the individuals involved to best use their knowledge, skills and immediately available resources to achieve the best outcome possible for the situation.

It originated from the aeronautical industry as a way of trying to understand why crashes and mishaps occurred and then identifying strategies to prevent their recurrence. A lot of the language and characteristics of the CRM process have been ported over to various areas of medicine, with a number of groups and individuals working to figure out how best to apply these lessons to patient care.

Crew Resource Management (CRM) is also known by several different names including Crisis Resource Management and Cockpit Resource Management. However, direct extrapolation from aeronautics to another industry is not always valid and there often needs to be some tailoring of practice. So the term is often altered to fit and in motorsport medicine, it has been called Race Resource Management.

Regardless of the name, the key element of CRM is careful analysis of processes to identify the strengths and weaknesses leading to the developments of a strategy that promotes the best outcome followed by ongoing assessment to ensure that the target outcomes are being achieved and evolving as new information comes to light. It is an organic process.

2) Why should we care about CRM?

In general, when things are going smoothly, the stress levels are low and we feel like we are on top of our game. However, that time that we are really tested is when things are deviating from the intended trajectory. This is when a situation can feel like either a challenge or a threat, depending upon whether we feel that we have the requisite knowledge, skills and ability to deal with it. If any of these three components fail, the chance of error and therefore a bad outcome rises.



3) Knowledge and skills

These two components are what we spend most of our time and effort trying to improve. So if we are smart and have the right skills, why should anything go wrong? 

When we are calm, it is fairly easy to assess the situation, choose the correct course of action and act. In a crisis, the pressure is up and something akin to the fight or flight reflex may kick in. If we are not thinking straight, our approach to the issues confronting us may become unbalanced, leading us to apply our knowledge and skills inadequately or inappropriately or not at all.



Both System I and System II processes are useful and have their benefits and downsides. Understanding how they work and how we work with them can help us to refine how we behave when the pressure is on.

"Use your attention wisely"

4) Situational awareness

Simply put, this is our ability to remain aware of or environment and how it might evolve. 

A football player will be aware of roughly where their team mates and opponents are, how the ball is moving, the direction of play and where the goal is. Similarly, for a race track incident, there may be any number of items to remain aware of, such as the location of the incident, whether the yellow flags or safety car are deployed, is the car on fire, where are the rest of the race cars, what are the clinical priorities and whether it's more appropriate to go to the circuit medical centre or straight to the receiving trauma hospital. 

Under pressure, there is the potential to develop tunnel vision, either cognitively or literally. This can be due to:
  • Cognitive overload
  • Environmental overload
  • Communication overload
The result is becoming overwhelmed, which may lead us to being unable to effectively or appropriately apply our knowledge and skills.


5) Resolution

Cognitive and behavioural psychology

Understanding the concepts behind how we think and behave helps us to develop strategies to mitigate the error prone elements. There are multiple resource available to delve in here. Go check out the reference list below.

Cognitive off-loading
  • Pre-event planning and Standard Operating Procedures (SOPs) - How will we approach an incident? Role allocation. Exit strategy.
  • Checklists - These help to reduce the cognitive burden of certain activities, but they need care in their development. Go listen to this podcast: "Checklists" on Phemcast - https://phemcast.co.uk/2018/02/09/episode-27-checklists/
  • Rally points - Regular planned breaks in activity to perform a self and/or team catch up so that it is clear what the priorities are, what the intended targets are, how to get there and whether they are being reached.
  • Leadership and followership
Stress inoculation practice 
  • Sim training really helps here. 
  • Debriefing is critical and is where most of the learning is made explicit and concrete. 
  • There should be specific, achievable objectives. 
  • Start gently and build up as abilities and confidence grows.
  • Practice should be deliberate. 
  • Mixed team and mixed skill training not only improves knowledge and skills but also improves team cohesiveness.

The podcast



The intro music clip is from Music For Pleasure - The Human Factor (7'' Version)
https://www.youtube.com/watch?v=qT_e_v4K1cA



The slides

(These are the slides from David's talk at the ICMS Congress)

Crisis m anagement final from DavidHakim83

References and resources
Finally, Dr Andy Buck has a whole website devoted to clinical CRM and human factors strategies called Resus Room Management - http://resusroom.mx/