1. DEALING WITH INJURIES A Guide for Rugby Referees

3. KEEPING THE GAME SAFE M. Bruce Carter, MD December 4, 2007

4. Good Samaritans with Whistles  Duty of Care?  Level of expertise/training  Help may be refused  Implied consent  Don’t stop once you start  No obligation to incur risk

6. Pre-existing Arrangements  Ask ahead of time  Assume anyone responding to an injury is qualified (until further notice)  Cell phones are everywhere

7. Primum non nocere  Don’t make it worse  Don’t let someone else make it worse  This includes the injured person

8. What is Serious?  Bleeding  Inordinate pain – blow the whistle  Unexplained sensations  Life or limb  Obvious deformity  Loss of consciousness

9. Stabilize the Situation  Whistle  Full attention  Eliminate further danger  Minimize movement of affected part/person  ‘Neutral’ position  Comfort, hydration, shade/warmth

10. Call For Help  Qualified folks on scene  If you think about it – activate the EMS

11. If In Doubt – Don’t  Don’t move an injured person if it might make them worse  Don’t take any action for which you have no good reason

12. The ABCs  Airway  Breathing  Circulation  Disability/Damage (neurological), Depth of Consciousness  Everything Else

13. Head Injuries  This is how rugby players die  Bloody noses, black eyes, dangerous tackles, scrums and ‘normal’ tackles  Fortunately, this allows for preventive care

14. Guidance from the IRB  “A player who is suffering definite concussion should not participate in any match or training session for a period of at least three weeks in any match or training session for a period of at least three weeks from the time of injury, and then only subject to being cleared by from the time of injury, and then only subject to being cleared by a proper neurological examination.” a proper neurological examination.”

15. Concussion Defined  A period of altered consciousness in response to a head injury  What the IRB calls ‘definite concussion’ is what physicians call a Grade 3 concussion

16. The Key Question - PEARL  HOW DID YOU GET TO THE GAME TODAY?

17. Grades of Concussion www.aan.com www.aan.com  Grade 1: ‘Bell rung’ – NO LOSS OF CONSCIOUSNESS – back to normal within 5 minutes  Grade 2: NO LOSS OF CONSCIOUSNESS – Not back to normal, feels ‘off’, after 5 minutes  Grade 3: ANY loss of consciousness

18. Treatment for Grade 1  Back to normal within 5 minutes  Rest and observation for 15 minutes  No further symptoms: okay to participate  Second Grade 1 = Grade 3

19. Treatment for Grade 2  Still not completely back to normal after 5 minutes  No further strenuous activity for 1 week, subject to professional examination and clearance

20. Treatment for Grade 3  This is what the IRB refers to as ‘definite concussion’  “I think I was out for a second” – no further activity. IRB Guidance applies – 3 weeks’ rest, professional evaluation  Unconscious for more than one or two minutes – activate EMS  Seizure activity – activate EMS

21. Preventive Treatment  Do not let concussed players continue to play  Inform coaches/teammates/friends/family of your concerns and recommendations  Rugby players look out for their mates better than they do for themselves

22. SUMMARY  RUGBY IS ONLY A GAME  Safety is part of our charge  You care or you wouldn’t be there  You’re intelligent or you wouldn’t be there  The Law and the law are on your side  Ask for help and trust the helpers  “Preserve the fighting strength”