When someone yells “You da man!”, to me, I’d expect that I just hit a 280 yd drive or that I just nailed a 360 off a ski jump.
Although those would be damn cool (since I seriously doubt I could do either any more), I am just as psyched when a Dad yells that at me right after I successfully reduced his 2 y/o’s nursemaid’s elbow after two other people failed to do so.
I kinda felt like taking a victory lap.

So, I remember during my residency when I was doing my peds ER rotations, there were some totally stupid things I was forced instructed to do or not to do. Since then, I have totally changed my practice when it comes to treating kids in the ER (I see about 10-20% peds). These changes occurred because I realized that so much of what I was taught made zero sense and was usually not remotely supported by an evidence. It was just the way they did things.

Let me preface this though by saying that the vast majority of the attendings that were practicing emergency medicine back then were not ER or even Peds ER trained. They were just pediatricians with no specific ER training. Things probably have changed somewhat in Peds ERs as more people have done the training so I imagine their practices have improved.

Anyway, one thing that really used to piss me off what that kids (which could be defined up to age 18) “were not to get anti-emetics or anti-diarrheals” in the ER. What?!?:! Why?! We had Zofran back then which is pretty safe and Imodium so what not give them something for relief of their (nearly universally viral) gastroenteritis?!? I used to argue all the time.

Another was that there was this annoying reluctance to give steroids to all asthmatics. I’m sorry, there are many studies that show that steroids greatly reduce the bounce back rate. I give them to virtually everyone that that comes with asthma, no matter the age.

Worthless big workups. This is still a problem. Older docs especially used to do blood cultures, urine cultures, and even sometimes LP’s on kids if their fever was “too high” like over 104. Now, I am not talking about really little kids under two months – but the would do it to almost every kid who had a high fever for a day if it was high unless there was an obvious source, even in kids that looked totally fine. Worthless, invasive, and expensive.

And finally, unnecessary conscious sedation for kids with minor lacerations or other injuries. I used to have to put a 2 year old on Versed and Morphine for 1 cm lac that required 3 stitches. I mean, come on, PAPOOSE BOARD! It’s not like they are in terrible pain, it just they are scared – and you know what, they will get over it!

So, now that I have been out practicing and seeing kids for years (and having a few of my own), I have greatly streamlined the treatment of my peds patients, saved money, and generally treated them more responsibly. And now, the parents like me more too. Of course I still argue with the old outpatient docs who send kids in for stupid stuff and ask for big work-ups and unnecessary consults but that’s never going to end I’m sure.

In the wake of the very tragic death of a 16 year old shortly after getting hit during a football game in upstate New York, I thought about all the kids I’ve been seeing recently in the ER who’ve gotten injured during games. Part of me thinks this is good – I imagine in the past there was less pressure to get kids checked out so perhaps with all the recently scrutiny, coaches, parents, and players are more likely to come in. However, part of me thinks – is this worth it? I know that such tragedies are rare (thank god), however, it seems we hear about more and more of them.

Maybe it’s just that it is more reported in the news (like child abductions for instance – we hear about every “Amber Alert” across the whole country these days even though abductions are no more common now then they were when I was a kid), or maybe there really are more deaths. I asked myself this question and did a quick literature search. It seems that the rate of deaths (and severe head injuries in general) has remained relatively steady and low since the modern football helmet was developed in the late 70′s. However, it seems deaths are more common in high school than in college and the pros. Why is this? It’s not clear but it seems that many severe injuries occurred when the player remained in play after a recent concussion and was still suffering residual effects.

As a parent, I can say that I would not likely let my son (or daughter) play football (not that I presume they’d even have the skill for it). I would just be too scared. In my opinion, the main flaw of the sport (even though I love to watch it) is the concept of downs. Why? Because after 4 downs, you give up possession. The pressure to get that 10 yards is ever pervasive. It makes one try to max out their stretch and their hits (on both defense and offense) to get or prevent that little bit of extra distance. Add this to the fact that when you have full padding (including helmet) you may feel invincible. You are trained to put your head down and ram your way through. I see this as a recipe for disaster.

Now, this brings up another similar rough and tumble contact sport, Rugby. American football is derived from it (and if you research it, you will find all sorts of terminology and rules left over from Rugby) but now is vastly different. I am talking by the way about traditional Rugby – Rugby Union as opposed to Rugby League. In Union, the whole concept is to keep the ball moving. There is no limited number of downs (scrums or scrum downs (which is where the term comes from by the way)). There is no rule that you have to go 10 yards to maintain possession. You can lose yardage and still keep the ball. In my opinion (and in many other’s) this lack of pressure to eek out a few more yards prevents one from lunging forward when you are about to get tackled. You are supposed to turn and take the tackle with your side or back and then pass it to some other player or let your team mates come in and support you, forming a maul or ruck. In fact, lunging forward or not turning is more likely to allow the other team to take the ball into their possession.

Second, the lack of headgear and heavy padding (which is worn in Rugby league usually), I think protects players from concussions! How is this true. Well, when you don’t have a helmet, you protect your head! You don’t ram into things! Now, of course concussions are not infrequent in rugby but if you added helmets, I guarantee they’d be more common. Now, Rugby League (played more often in the north of England and parts of Australia) is a little more like American football. There are 6 downs (called “tackles”) given the attacking team for them to score before the ball is turned over. Also, players tend to wear more protective gear, especially the forwards (who are kind of like linemen). Still, there is no blocking or forward passes, the two hallmarks that define American football. I haven’t done the research into it but would not be surprised if head injuries were more common in League vs Union.

Anyway, I guess since I played Rugby in school I am a little biased but recall that head injuries were not that common (compared to shoulder and knee injuries). I see there being major challenges to make American football safer (especially for minors) and not change the rules of the game dramatically. Some will be technical – better helmets obviously. Second, mandatory rules that kids that take hard hits to the head come out of the game. And anyone with any concussive symptoms be evaluated by a doctor (or midlevel) and not be allow to return to play until they are completely back to normal, even if this means sitting out numerous games. It is just not worth it.

For a great article on Rugby Union and its injuries, check out this one. It’s available as a full text article.