What’s a World Cup without controversy?

Uruguay’s Alvaro Pereira

Followers of this blog will know I have just returned from Quebec City, where I spent a fabulous four days catching up with professional colleagues from around the world at the 2014 FIMS sports medicine conference.  The event was hosted by the Canadian Academy of Sports and Exercise Medicine (CASEM), who conjointly held their annual meeting with FIMS.

Followers of the vastly bigger event known as the World Cup will know during this same period, there was the medical (mis)decision seen around the world involving Uruguay’s Alvaro Pereira:  knocked unconscious, and subsequently allowed to return to the pitch.

In truth, I got to see the event live, along with hundreds of millions of other people on the planet.  On a break in between conference sessions, I was in my hotel room. I had the television on while working on the laptop, when I noticed the downed Pereira.  My initial glimpse of his limp body was first out of context, which is to say I didn’t see the hit live, and I had yet to see the replay; my initial reaction was to fear the worst, as Pereira’s entirely limp body had me concerned he had suffered a cardiac event.

Quickly, though, I got to see the replay–the knee to the head–and it all made sense to me.

What followed, in some ways, made no sense.

Like the others in the viewing universe, I saw Pereira attended to by his medical staff.   As he got to the sideline he started to vigorously protest the intended substitution; and, of course as you all know, Pereira eventually made his way back to the pitch……

And at that moment I saw the twitter universe explode.

At the very least, the 2012 Zurich Consensus Statement on Concussion in Sport was being honored in the breach rather than the observance.

Just a smattering of the tweets:

@MizzouSportsDoc “Disappointing to see another clear concussion in soccer completely ignored by the medical staff/coaches. FIFA has to address this #URUvsENG”

@_playsafe “Hard to enforce concussion policies at community level when FIFA fails at World Cup setting terrible example.”

@DrJohnOrchard “NY Times is calling it & I agree. It is hard for Drs to properly manage concussion in sports with few substitutes.”

The subsequent debate has been heated, with the NY Times weighing in with “‘Lights went out, but he kept playing.'”  @MizzouSportsDoc (that’s Dr. Aaron Gray, a team physician at University of Missouri, a friend and colleague) had a few more cogent tweets coming right after the initial injury.  He noted a dangerous tackle Pereira made and speculated that this represented the sort of poor judgment one might  see precisely in an individual who had just been concussed.   I thought that was a powerful insight:  that post-injury concussion management represents injury prevention not only for the concussed individual, but possibly for others on the playing field as well.

I want to begin my brief discussion with a sincere disclaimer that I do not want to directly criticize the medical staff of the Uruguay team.  I truly believe in ‘the fog of war’:  that in the heat of battle, or sport, decisions can become complicated.  I believe as well in the truth of Teddy Roosevelt’s speech about ‘The Man in the Arena‘:

The great T.R.: add football commentator to his list of accomplishments

“It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena…who strives valiantly; who errs….because there is no effort without error….”–Teddy Roosevelt, speech at the Sorbonne

It is easy to ‘Monday Morning Quarterback,’ as they say here in The States:  to state how I would have done something, if only I had been there….

I think it much better–and I hope that this is what FIFA intends to do–to look at the situation deeply, and look at how such a situation can be avoided in the future.  Much of it has to do I think with the power that the Team Physician has in the middle of a game, most especially a game of significance like the Uruguay v. England match.  Much of it has to do as well with the nuances of the soccer game itself:  that a substitution for Pereira, even to allow the medical staff to do a thorough examination and calm the player down, means automatically that the player is out.

Some of it may have to do with knowledge transfer.  I find it hard to believe that the Uruguayan Team Physician is not fully aware of the up-to-date management of sport concussion, but I could be wrong. “Knowledge transfer” and “behavioral modification” are two public health concepts that apply here; I do think we have seen a sea change in how concussions are diagnosed and managed here in America in sports such as gridiron football, largely because of educational initiatives whose lessons have been adopted by important stakeholders.  But even now I am sometimes surprised by the lack of knowledge and persistence of regressive behaviors around concussion in people ranging from players, to parents, to coaches and even physicians.

There are no perfect solutions here, but a different football code–rugby union–has, with IRB (International Rugby Board) backing, developed I think an enlightened policy, allowing a temporary substitution and a five minute evaluation by a team medical staff to determine if a player can be returned after a head injury or whether the temporary substitution can be made permanent.  This is akin to the so-called ‘blood replacement’ rule of rugby union:  a player with a wound such as a laceration can be temporarily substituted for up to fifteen minutes to allow the medical staff to attend to the wound and get the player fit for the pitch.

FIFA might consider a similar substitution policy to allow medical staff some ability to make more correct judgments on the pitch.

I am sincerely interested in what you all have to think, most especially about how we can move forward to minimize these sorts of occurrences.

I want also to point readers to the resources we have here at CJSM addressing the issue of concussion in sport.  We have an excellent, and freely available, “Concussion Collection” I would commend to you, full of a variety of articles  We recently had a podcast with authors Oliver Leslie and Neil Craton, who delivered a strong critique of the 2012 Zurich consensus statement:  listen to it here.  And these days, there doesn’t seem to be an issue of the journal that does not include some article or original research on the subject:  the May CJSM has original research looking at the different mechanisms of injury in concussions seen in University football, ice hockey and soccer….and there is more coming in the July issue, which will publish in just a week (shh…I can’t tell you yet what’s  in it, but soon…….you’ll see!)

So give us a shout (politely) here on the comments section of this blog about the Pereira incident.  We’re always interested in what you have to say.