On Call and Evidence Based Medicine


Calling Dr. MacDonald…..

When I am ‘on-call’ for my sports medicine clinic practice I receive a mixed bag of phone calls.  The calls come in from patients we take care of, to emergency physicians looking for help triaging patients, to community physicians looking for consultation. Because I do non-operative, primary care sports medicine, I’m rarely involved in an emergency when ‘on-call'; any urgent or emergent issue I need to manage typically occurs when I am on a sideline and not nominally ‘on-call.’

Last week, I received an interesting query about muscle pain in a high school runner who had been doing some intense pre-season training.  The physician seeking my advice had felt obliged to check the patient’s creatine kinase (CK) and told me the level was 1400 U/L.  He had already obtained a urine for myoglobinuria (negative), and he was asking if he should be clearing the patient to return to sport.

Most of my clinical work involves taking care of fractures or concussions, spondylolysis or osteochondritis dissecans.  As with a lot of clinicians, I suspect, for the conditions I treat in high volume I have the facts usually at the tip of my tongue.  Though I have manged the condition, I don’t routinely treat patients where rhabdomyolysis is in the differential.  And so, with this specific phone consultation, I assured the physician the patient was in no imminent danger, but I wanted to get back to him later that day after I had done a literature search.

Though I did not think about this explicitly at the time, I later realized that this little vignette represents an example of “Evidence Based Medicine” (EBM) in use.  As Sackett et al. state in 1996, “Evidence-based medicine is the conscientious explicit and judicious use of current best evidence in making decisions about the care of individual patients.”

In this particular case, I wanted to find some of the primary research done on CK levels in athletes in this age group.  Among the articles I pulled were two from CJSM:  “A Cluster of Exertional Rhabdomyolysis Affecting a Division I Football Team” , which was published in 2013; and a ‘Brief Report’ that was available only on-line until it was just published with the new, September CJSM, “Creatine Kinase Levels During Preseason Camp in National Collegiate Athletic Association Division-I Football Athletes.”

The former study I have actually profiled in these blog pages before.

There can be limits to the application of EBM in making decisions about ‘individual patients.’ Read more of this post

Case Reports


Multiple Mandibular Fractures

I am writing a chapter on facial trauma in sports and am learning quite a lot as I go.

For many of you, I am preaching to the choir when I write that teaching is one of the best ways to learn.

My charge in this chapter is to cover many aspects of maxillofacial trauma, including entities I may have dealt with infrequently, or have referred promptly and never directly handled myself (maxillofacial trauma not infrequently requires surgical intervention).  That’s where the teaching–or writing in this case–as learning comes in.

I have seen my fair share of facial trauma during sideline coverage of sports.  Aside from simple contusions, I would estimate that the most common entity I have to deal with is facial lacerations, followed by nasal fractures and epistaxis.  But I have never conservatively managed an athlete with a frontal bone fracture.

One of the offerings in the journal that is relevant to this subject is our ‘Case Reports’ section.  I think the Original Research our journal offers is our strongest suit, but the published case reports cover such a wide variety of subjects, I find that I can learn a great deal from them.  This is most especially true if an author is reporting on a truly novel case or treatment.   I specifically leaned heavily on a specific case report in the writing of my chapter:  “Conservative Treatment in an Isolated Anterior Wall Frontal Bone Fracture in an Elite Soccer Player,” by C Eirale, R Lockhart, and C Hakim, in the 2010 CJSM.

I am citing this journal article in the writing of the chapter, as I found it to be full of useful information.  Frontal bone/sinus fractures can result in serious morbidity (ranging from chronic sinus dysfunction to meningitis); surgery is often indicated.  In this particular case, the authors and treating physicians felt they could treat conservatively, given that:

“(1) no posterior wall fracture on the imaging; (2) absence of cerebrospinal fluid (CSF) rhinorrhea; (3) integrity and patency of nasofrontal duct (no fracture on imaging and no signs of mucus or blood retention in the sinus); and (4) absence of laceration over the fracture (allowing a direct access for reduction and osteosynthesis).”


Rod of Asclepius

The soccer player made a remarkably quick recovery, playing a match (with facial protection) only three weeks after this serious injury.  How’s that for mending the wound!  Those sports clinicians would make Asclepius proud!

The journal’s Case Reports editor looks for discussions of novel pathologies or treatments.  Most of our submissions are solid but must be turned away because they do not follow our strict criteria for consideration of publication for these type of reports.  Our Case Report for the most recent, July 2014 CJSM is a good example of  what we look for when deciding to publish.  The case deals with the use of pulsed ultrasound (LIPUS) in the successful treatment of a delayed union of a hook of the hamate fracture.  We thought this was an uncommon enough pathology, with a novel treatment approach, to be considered worthy of publication.

And now,  I head back to writing the chapter.  A September 1 deadline is looming.  With football season nigh (first game is Friday evening August 29), soon enough I won’t be writing (or reading) about such injuries……I’ll be too busy handling them on the sideline!

There’s a lot coming up both in the world of sports (US Open tennis, the first kickoff of the American football season….) and the world of sports medicine (our 5th edition of CJSM for the year is about to publish). I have some great guests lined up for some upcoming podcasts.  It will be a great fall.  See you again soon on-line!


New Concussion Research from CJSM


claire and katie

With the dog days of summer come concussions. And with concussions come research!

I think of August as the ‘lull before the storm':  with the dog days of summer come two-a-days in American football.  Around the country, the school  fields fill with kids playing the most popular contact sport in the U.S.:  football, to an American; ‘gridiron football’ to the rest of the world.

And with these days we begin, in our clinics, to see a steady, inexorable rise in the number of concussions to be evaluated. By mid-September, we can’t seem to open enough clinic space to see everyone clamoring to get in.

Last year, at this time, I wrote a post on the freely available concussion offerings we have at CJSM, and I am re-posting that entry(see what follows this new entry, below) for folks to read and see what we have in store when you visit the main website.

Over the past year, we have published many additional research articles, some of which are in the print queue and only available on line.  I wanted to draw your attention to a couple of those offerings, as they have real, clinical impact on the way we may practice.

The authors Carrie Rahn, Barry Munkasy, Barry Joyner et al.  looked at the BESS test as performed on the sideline of actual events, and found that the test performance deteriorated when compared to more controlled environments.  They conclude that ” Clinicians need to consider the role of the local environment when performing the BESS test and should perform postinjury tests in the same environment as the baseline test.”

And a very interesting article with a group of authors including Bob Cantu and Chris Nowinski looked at the efficacy of concussion education programs and determined:  “Preseason concussion knowledge was not significantly associated with in-season reporting behavior. Intention to report concussion symptoms was significantly related to in-season reporting behavior.”   Important to the understanding of this article is their discussion on the psychosocial construct of ‘reporting intention.’  As ever, one finds in the realm of public health that education alone is unlikely to alter behavior.

Read these studies: “Sideline Performance of the Balance Error Scoring System During a Live Sporting Event” and  “Concussion Reporting Intention:  A Valuable Metric for Predicting Reporting Behavior and Evaluating Concussion Education,” by Emily Kroshus, Christine Baugh, Daniel Daneshvar, et al.

There’s a lot to learn!



Originally posted on Clinical Journal of Sport Medicine Blog:

We’ve been profiling sports-related concussions (SRCs) in the August posts here on the CJSM blog.

We’ve taken a peek at the use of computerized neurocognitive tests in the diagnosis and management of SRCs; conducted a poll on the entity known as “Second Impact Syndrome”; and interviewed Dr. Jason Mihalik of the University of North Carolina, who is one of the principal developers of a celebrated app helping laypeople identify when an athlete might be concussed.

In this post, I wanted to alert the readership to a special set of journal articles CJSM is releasing for free for a limited time, a set devoted to this issue of SRCs.

chris hughes 2

No, that’s not “Big Brother,”
that’s the CJSM Editor-in-Chief,
Christopher Hughes MBBS, MSc

Our Editor-in-Chief, Dr. Chris Hughes, describes the special collection of ten journal articles in this YouTube video.

I am very excited to pass this…

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Published On-Line First


What we once dubbed ‘Published Ahead of Print’ (PAP), we now call ‘Published On-Line First‘ (POLF???). Whatever the phrase or acronym, I can attest to the benefit as an editor, a reader, and an author.  The publication flexibility that publishing on line provides is extraordinary.  We get many excellent manuscripts submitted for consideration.  The few that make it through our rigorous peer review must then wait in the queue to get on the actual pages of the journal; and so, with publishing on line, we can make the authors’ scientific findings available immediately, even before we have copy on paper.  The articles are immediately found on PubMed and are citable with their unique digital object identifier (DOI) number.

As a reader, I enjoy this functionality.  I rarely get my medical information any more from paper.  I still receive CJSM and other journals (Sports Health, JAMA, MSSE, etc.) in the mail.  I might page through them as I eat breakfast; I will have them on my nightstand to skim prior to sleep.  But most of the time, I am reading my medical journals on the laptop or iPad.  Or I’m sharing a link to a study with someone on twitter.  All of this can only be done with an on-line publishing functionality.  It’s brilliant.

Finally, as an author:  it is always exciting to get your manuscript through peer review.  Always exciting to see the months to years of hard work culminate with an accepted manuscript.  Historically, one would then wait for some time before actually seeing the manuscript in print.  Now, once a CJSM author has completed their post-acceptance corrections, reviewed the galley proofs, and so on, their work can be disseminated immediately.  As an example, here is a recent bit of excitement I just had as an author in the pages of CJSM: ‘Reliability of a computerized neurocognitive test in baseline concussion testing of high school athletes.’ 

I am off on vacation, and so I thought I would share a post on PAP from 2013.  More soon!

Originally posted on Clinical Journal of Sport Medicine Blog:

Time to time, I like to share with readers of this blog some of the features of CJSM with which they may not be familiar.  Our journal’s website has a wealth of resources that I’d encourage you to check out regularly.

For instance, besides publishing the full journal every two months, we frequently disseminate breaking sports medicine research in a more fluid, continuous fashion via our “Published Ahead of Print” (PAP) feature.  PAP allows us to pursue a major goal we editors have:  to contribute to the world of clinical sports medicine in a contemporary fashion, taking advantage of the multi-media offerings of the digital world.   This goal is reflected in this blog itself; in the podcast feature we have just begun; in our engagement with you on social media; and in the journal’s iPad functionality.

“When you want it….where you want it…the way you want it.”  That’s…

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