A sporting chance
Doctors who have been influential in making their sports safer
The inherent competitiveness of sport means that its competitors are sparring against each other to come out on top, and because of this there is inevitably the risk of injury.
Doctors can be involved in providing medical assistance in various ways at sporting events. Probably the most common is the role of a sports medicine doctor who provides individual care to a professional athlete or team. There are also immediate care or pre-hospital emergency medicine doctors involved in responding to a major injury or trauma at the scene and overseeing the transition to definitive care—for example, a hospital. Common injuries these doctors might deal with are traumatic injury, spinal injuries, or incidents such as hypertrophic cardiomyopathy, which is a leading cause of sudden cardiac death in young athletes.
However, while doctors respond to injuries as and when they occur, some have played a vital role in identifying preventive measures to minimise the risk of harm to the men and women under their care in these competitive arenas. Sports medicine doctors must be aware of how to identify these risks and are expected to recommend ways of making the sport safer for those who compete.
In this article we have profiled some doctors who have made important contributions to improving the safety in their sports—sometimes in response to fatal incidents—which safeguard the competitors under their care from long term or serious injury.
Mark Gillett, director of performance at West Bromwich Albion football club, says that “while the techniques of managing an athlete’s general medical issues have developed over time, the most significant developments with regard to player welfare have been the introduction of guidelines and compulsory advanced life support and trauma training.”Gillett was contacted by Alan Hodson, the then chief medical officer of the Football Association, to produce such a guideline in 2006 in response to a head injury sustained by Chelsea Football Club goalkeeper Petr Cech. Cech had a depressed skull fracture after colliding with an opposing player’s knee when diving for a ball. Cech survived the incident and still plays today—albeit with a protective rugby-style head guard. “Despite the outcome being satisfactory, there was an increased need for structure and regulation in the process of getting footballers to hospital.” The guideline Gillett developed ensures that all medical staff in the premier league have undertaken a standardised emergency care qualification, and gives clear guidance relating to pre-hospital care that all clubs are required to adhere to. It covers standard medical care and logistics, and outlines structures to tackle just about every eventuality before an injured player’s transfer to hospital.
What effect has this guidance had? The guideline Gillett produced applies specifically to “life or limb” situations, and as such has been put into practice relatively little. One high profile application, however, was in March 2012 when Fabrice Muamba was playing for Bolton Wanderers against Tottenham Hotspur in London. Muamba had a cardiac arrest on the pitch and after a lengthy period of CPR in the stadium, was transferred to the London Chest Hospital under whose care he survived the incident. The guidelines put in place after the Cech incident greatly improved his chances of survival, and according to Gillett, “had that occurred 10 years previously, there may not have been the same result.”
When Michael Turner joined the British Horseracing Authority (BHA) as chief medical officer in 1993, despite its profile as a dangerous sport, medical provision was still lacking. “It [has] not been long since the role of racecourse doctor was virtually honorary,” wrote 18 times champion jockey Tony McCoy—the role was seen as “a good job and a free lunch for a retired GP.” Coming in with 18 years experience with the British ski team, Turner introduced a number of drastic changes which saw jockey welfare improved rapidly. His first introduction was routine drug testing in 1994. “It was not in essence to detect any performance enhancing substance use” said Turner when interviewed, “but to ensure that all jockeys were safe to ride and would not pose any hazard to others.”
The death of jockey Richard Davis in 1996, who fell from his horse while racing at Southwell Racecourse, Nottinghamshire, sparked the overhaul of event safety and the introduction of strict rules and regulations concerning medical cover at every racecourse, which Turner had been suggesting for a number of years. “It became a requirement of all racecourses to provide two doctors and two ambulances on every race day,” said Turner, “and all the safety equipment along with the jockey’s safety equipment needed to be approved, maintained, and standardised, as well as the qualifications of the supervising doctors.” Work was also done to improve the quality of care. “It became a requirement for doctors to have undergone a BHA approved pre-hospital emergency care course in which they had to re-train every three years to stay up to date.”
Rugby union players often pride themselves on the toughness and physicality of the sport. In no place is this more true than in South Africa, which is renowned for producing some of the fiercest players in the world. However, when Tim Noakes, a doctor and professor of sports science at the University of Cape Town heard a top flight Currie Cup match in Cape Town in 1980 on the radio it was shockingly apparent that the standards of medical care did not match the risks of such a physical game. Western Province player Chris Burger had a catastrophic spinal injury in the match and had to be stretchered off prone on a changing room door as there was not a proper stretcher in the grounds. He died a day later of his injuries. Things clearly needed to change and Noakes felt a responsibility be part of a movement towards safer practice.
He began by forming the Sports Science Institute of South Africa in Cape Town and a national research programme into the factors that cause critical rugby injuries. The programme pointed towards the widespread suboptimal care. In “only 50% of cases were medical personnel present at the time of injury,” said Noakes, “and 49% of injured players waited longer than 6 hours for acute management of their injuries.” Only in 5% of cases was it deemed the injured player had received optimum medical care.
It was this data, collected over 27 years and published in 2007, that led to the development of the “BokSmart” programme, which focuses on developing evidence based protocols for “injury prevention, injury management, rugby safety, and player performance with specific attention on serious and catastrophic head, neck, and spine injuries.” This is primarily done through the education of coaches and referees, but also through innovative services such as the BokSmart spineline—a daytime emergency helpline solely for potential serious concussion, head, neck, and spine injuries sustained during a rugby match or practice. Services are designed to cater for all players in South Africa, with an emphasis on accessibility for disadvantaged communities where evidence has suggested poorer outcomes from injury. Noakes described the establishment of programme as a “monumental mind shift for rugby authorities.”
However, the task of improving safety in rugby union in South Africa has not been without its setbacks. Charged by some as trying to “soften” the game of rugby and caricatured as an anti-rugby figure by influential figures in the South African Rugby Board (SARB), Noakes’ recommendations regularly fell on deaf ears and he was even “actively prevented” from accessing data regarding spinal injuries in one South African hospital by the then president of the SARB. It wasn’t until Noakes and others had collected a mountain of evidence that the SARB softened its stance to Noakes’ recommendations. Noakes is happy that everything that his team had called for over 25 years ago has “finally been put in place.”
Getting involved in sport and exercise medicine
Only founded as a specialty in 2005, sports exercise medicine offers a varied range of opportunities for future physicians. Liam West, founder and president of the Undergraduate Sports and Exercise Medicine Society, says there are three key aspects to sports exercise medicine. “The first is dealing with injuries and illness in sport.” This is the traditional role of a doctor looking after the health of individual athletes or teams and “may include everything from dealing with their coughs, colds, and diarrhoea to diagnosing and managing their sports related injuries using tools such as ultrasound and platelet rich plasma injections.” The second is concerned with physical activity as a preventive and therapeutic treatment in non-communicable diseases such as diabetes and osteoarthritis, “the so called exercise polypill prescribed in personalized exercise prescriptions. This also encompasses public health and looking at how exercise can improve the health of a population as a whole.” Research is the final aspect, in order to find the optimal treatments for different sports injuries or looking at the science of exercise, its physiological effects on the body and how it can help cure disease.
There is variation in the way in which sports exercise physicians can practise. Working for the NHS or privately, they can do anything from simply putting on sports medicine clinics to being involved in a multidisciplinary team, as is the case with team doctors. West says that you don’t have to be a top athlete or even enjoy sport to work in the specialty of sports medicine. “SEM could suit a lot of people, from those wishing to do something hands on such as ultrasound or injections to those who like the diagnostic challenge of sports injuries received as a tertiary referral.” Foreign travel can also be another draw, “In a role as a team doctor someone could travel the world from the base of their home city.”
How can I increase my chances of becoming an SEM doctor?
The 2012 Olympic Games in London included 5000 medical volunteers, who were stationed around all the sporting venues and also at the athletes Olympic Village to offer support to competitors who were preparing or recuperating from the games. West says the best way to get involved in SEM is at undergraduate level in your local SEM society and to try and gain as much experience as possible working with doctors who look after athletes and with teams in a volunteering capacity.
Undergraduate SEM societies are at most medical schools around the country and USEMS (Undergraduate Sport and Exercise Medicine Society) can help you set up your own society. More information can be found at http://www.fsem.co.uk/training-education/undergraduates-usems.aspx.Steffan Griffin, third year medical student1, Trystan MacDonald, third year medical student1
1University of Birmingham Medical School
Correspondence to: firstname.lastname@example.org
Competing interests: SG is on the Royal Society of Medicine’s Sport and Exercise Medicine Council.
Provenance and peer review: Commissioned; not externally peer reviewed.
- BMA. An information resource for doctors providing medical care at sporting events. 2014. http://bmaopac.hosted.exlibrisgroup.com/exlibris/aleph/a21_1/apache_media/98SVHD88IE68LN7UKTXJGB9CSYH6DG.pdf.
- McCoy T. Farewell to Dr Michael Turner, the man who saved us from ourselves. The Telegraph 2014. www.telegraph.co.uk/sport/horseracing/10580714/Tony-McCoy-Farewell-to-Dr-Michael-Turner-the-man-who-saved-us-from-ourselves.html.
- Hermanus FJ, Draper CE, Noakes TD. Spinal cord injuries in South African Rugby Union (1980–2007). S Afr Med J 2010;100:230-4.
- Boksmart, 2014: http://boksmart.sarugby.co.za/content/what-is-boksmart.
Cite this as: Student BMJ 2014;22:g3556