The Pressure of Decision Making: Head Injury Reflection

I have the utmost admiration for the Australian medical team following the Steve Smith head injury in the Ashes last week. In a very difficult, high profile situation, with millions watching and a lot riding on their decision, they remained calm and followed their own team's protocol with the highest regard for the player's safety. Some may think that that's an easy decision, Australian National Cricket squad and very experienced medical team following a protocol, simple? However, as a therapist at that level, to be able to take the emotion out of that situation and remove a high profile player takes huge resilience and mental toughness which I believe would be challenging for any dedicated therapist.

The topic is now being discussed and highlighted some issues as to whether the player should have been allowed back onto the field of play, with latent developed concussion symptoms evident. I will leave my own clinical views out of this, as only the people directly involved with the Australian Cricket team know the details and by all accounts, they followed their own protocol and return to play strategy to the letter. It does, however, highlight the tremendous amount of pressure and scrutiny put on medical staff in top level sport and I have to ask and wonder if they/we are getting the support to help deal with such situations.

Is psychological help readily available for support staff in squads at the top level? If it is, what percentage of medical staff do you think would take up the opportunity to seek advice or help, mid way through a top level competition with training, turn around for next comp and trying to look after a squad of 15+ athletes over a 4+ week period? A lot of therapists, of course, manage this really well and there are some good strategies now being put in place by forward thinking medical teams, to monitor support staffs mental health. Back in the day, I would never have considered asking for help, or 'ask for a chat' during a comp. One, because sometimes you barely have time to go to the toilet or eat let alone 'chat' and two, because I felt like it would be holding me back from doing my job or would look like I couldn't cope... how wrong and naive I was as a budding young physio :)

Sheffield Hallam Hockey Club - Alex Humphreys Head Injury

I would like to share this story from early in my career, which to date, is the most challenging situation I have ever been faced with. I want to add that I have had permission to share the details of this athlete, he made a full recovery and is now working as a budding young Physiotherapist himself.

I had been the Physio at this amateur club for two years and had developed a great relationship with my squad and coaching staff. Following a call from one of the coaches one evening (I was working elsewhere), I was informed that Alex had been hit with a hockey ball from close range and what did I want to do? I tutted to myself and smiled (this player is always getting knocked and was slightly mischievous) as I was constantly getting players checked at A&E for knocks and odd minor hand fracture. I explained I would take him to A&E to get him checked just to be on the safe side. He was generally fine, big egg on his head but hadn't been knocked out and just had a headache. We chatted and joked on the way to A&E and were seen quickly due to the nature of the injury. He was thoroughly checked out with a full neuro screen and cleared for discharge with 'mild concussion'. I wasn't entirely happy with this, as now 1 hour later the pain in his head had become worse and he had gone very quiet (he was NEVER quiet). I questioned whether they thought he could have fractured his skull, but was told this was "very hard to do" and "very unusual" so we were packed off with painkillers and some advice. I was anxious, but trusted their advice and didn't want to make a fuss.

By this point, I had contacted his Mum to explain the situation and he would stay at my flat overnight to keep an eye on him. As we got to my car he vomited, so I took him back into A&E, walked straight into the triage area to 'politely' explain he was much worse and insisted on a CT scan. In recognition of the pain, he was now in they obliged, settled him on a trolley and sent him off for a scan. I called his parents to explain they were scanning as a precaution, reassured them, but explained they may want to head over and take him home tonight. The following events I don't think I thought I would ever go through as a Physio and I may delve into at a later date. The scan revealed a fractured skull and an extradural haematoma. Alex was promptly rushed through to Resus and blue lighted to the Neurosurgical team at the Royal Hallamshire Hospital. I am pleased to report that following two lots of surgery over the coming days Alex started to recover and after a lengthy break from hockey and his physio degree, he has now made a full recovery and returned to the sport he loves.

Tough Mental Challenges Faced

The 24 hours following the CT results were the most stressful and hardest I have ever had to face in sports medicine. By reflection, I have outlined below some of the main challenges I faced as the only Physio and only medically responsible person at the club:

1. Explaining to Alex's family when they arrived to collect their son with 'concussion', that he had actually sustained a serious brain injury and the next 24 hours were crucial.

- making the decision not to call them whilst they were driving

2. Calling the head coach immediately to mumble and break down over the phone and explain the situation.

- said coach then rushed to my side to try and support me whilst I tried to support Alex

3. Trying to reassure Alex that everything was going to be OK and remain positive when in truth I was getting different information from the doctors.

4. Making the joint decision with the coach to give out little or no information to the squad and player who struck the ball, M, until we had more information.

- we had a close knit squad and club and M was keen to know if he was OK so we were getting many messages.

5. Going over to talk to M in the morning when Alex was stable, to explain and sit down face to face to give him the support he needed.

6. Keeping close links with Alex's family overnight as they sat by his bedside and waited out the crucial few hours while he waited for surgery.

7. Remaining calm and focused whilst trying to make clear decisions for the benefit of the team and the bigger picture, when all I wanted to do was cry and sit by Alex's bedside.

8. Dealing with the personal emotional fall out in the following months and behaving like an overprotective mother every time a ball came within 10 yards of Alex's head on his return to play :)

All in all however traumatic at the time, as a squad and close knit hockey team, we got through it together and managed as a team to support Alex during his recovery. Without the great support of the club, coach and players during this time, I don't feel I would have handled the situation so well, so early on in my career.

Lessons Learned - Making Decisions Under Pressure

This is obviously an extreme case which thankfully doesn't happen that much, but as therapists, we are constantly put in situations where we may be individually required to make important decisions specifically at lower level clubs, that have a direct impact on players well being. The pressure to constantly try to make the right decision while trying to develop and be good at our jobs must place emotional strain on even the most resistant of therapists.

Over the years I have worked with some great squads, each one having different ways of working and some with great concepts to help look after the mental health of the support staff. Some of the concepts that have worked for me and I would encourage are as follows:

1. Know your players and get to know their personality in training and during a comp

2. Don't expect them to listen to you all the time - they know their own minds, find balance

3. Build up a good relationship with your squad and coaching team to develop trust

4. Link with a 'buddy' in the staff or gain a contact at home that you can talk to whilst away

5. Don't be afraid to 'offload' to a close friend (maintaining confidentiality)

6. Try and step back so you can think clearly

7. Try not to make quick and rash decisions and remain calm

8. Talk and be open with your athletes and coaching set up

9. Give clear medical advice to coaches/athletes and don't take their response personally

10. Be confident in your own skill and decision making

11. Give yourself time away when you are free and remove the 'uniform' for a while

12. TALK to someone if you are struggling or feel under pressure even if its the smallest issue - don't let things build up

These are my own thoughts and reflections and I am obviously very wise now ;) but most of these lessons I learned the hard way and allowed me to develop as a therapist, which I guess is part of the journey. As mental health is discussed more and more, I am pleased further strategies for support staff are now being looked at and encouraged. Many sports medicine teams are very well supported in the field, but my fear remains that whilst we try and cope with these pressure situations for the good of the team, are we all equipped and supported to mentally cope with the outcome?