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LIABILITY PREVENTION IN SPORTS INJURIES
(Tuesday, June 11, 11:30 A.M. -12:30 P.M.)

KIT GREEN:

We are fortunate today to have with us one of the country's most outstanding sports medicine expel Dr. Fred Allman is from Atlanta where he heads the Sports Medicine Clinic. The clinic was the first private clinic in the United States devoted exclusively to the prevention, diagnosis, treatment and rehabilitation of athletic injuries. I am well aware of this clinic because we lost one of our best women orthopedic surgeons from the University of Washington to the clinic in Atlanta. Dr. Allman has very impressive credentials. A graduate of the University of Georgia, Fred was a lineman on the footb, team. Dr. Allman attended the medical college of Georgia and did his graduate training in orthopedics at Tulane University Medical School. Dr. Allman is a former member of the Board of Trustees of the American College of Sports Medicine and has served as president of that organization. He has been chairman of the Board of Trustees of the sports medicine foundation of America and served on a panel oi orthopedic surgeons to examine professional football players in the NFL who have initiated grievance claims. Dr. Allman has received numerous awards for his contributions to sports medicine and physical fitness. He has written over four dozen publications in the field, including the Executive Fitness Desk Diary devoted to executive health. He has lectured throughout the United States on the preventior treatment and rehabilitation of sports injuries. In addition to operating the clinic in Atlanta, atte! ing and speaking at numerous sports medicine conferences and providing leadership on this subject, Dr. Allman is currently orthopedic consultant for Georgia Tech's athletic teams and the Atlanta public schc athletic teams. The topic for this session is Liability Prevention in Sports Injuries. I am pleased and honored to present Dr. Fred Allman.

FRED ALLMAN :

Thank you Kit. Thank you Homer and collegiate directors of athletics. I am very happy to have opportunity to be with you today. I have always enjoyed a very close relationship to athletics and £ the past quarter of a century or more, I have had the great opportunity of taking care of athletes at all levels of participation. For the past 17 years at Georgia Tech I have not missed a home or away For the seven years preceeding those 17, at the University of Georgia, I only missed the games while an official capacity at the Olympic Games in Tokyo. So, I have been on the sidelines at many games a' I have seen many injuries. I've had involvement with many different programs and I've gone into varf, communities in times of crises as a consultant. While I may not be the most interesting speaker, whL I may not be the best speaker, whiI-eI really may not be the most articulate speaker at this Conventiol I think what I have to say today will be more important than anything else that you many have heard, I at this meeting or any preceeding meeting. The things that I want to talk about today affect you 24 1 a day, 12 months out of the year, and can bring catastrophic results to your athletic program in secol Not in a matter of time.

Sports programs should be a positive influence. Injuries have long been considered an integral of athletic participation, especially related to the violent nature contributed to football. Consid, that over one and a quarter million students participate annually, and that these individuals are in direct confrontation with one another during competition, and from one to three hours during daily P' sessions, it is small wonder why an estimated 600,000 injuries may be reported during a single seas~

While many of these 600,000 injuries are minor, some are serious and a few are catastrophic. Three areas of special concern are related to head and neck injuries. These are the injuries that are most likely to produce death or paralysis; heat stroke problems, because they have a high fatality rate and because they are 100 percent preventable if the correct measures are taken, and knee injuries because knee injuries represent the single most frequent seriously disabling injury to the athlete. And the condition is most likely to terminate the career of the athlete prematurely.

The title of my presentation today is the medical legal aspects of sports. I would like to present a strategy for reassessment in management of the athletic program. This plan assures organizations control of the athletic program and offers promise of preventing injury and reducing the likelihood of liability. The primary and controlling objective is to reduce, to the lowest possible level, the risk of injury.

What does risk assessment and management strategy consist of? Minimize potential of injury and litigation through in-depth evaluation of key personnel and frequent inspection, maintenance and evaluation of equipment and facilities; the establishment of prudent administration policies and procedures; the anticipation of foreseeable problem areas; the development of common sense and good judgement for all involved personnel, especially as it relates to safety, and the development of cognizant skills relative to injury recognition. Sure, this program requires effort. It requires time. It requires some behavior modifications among all of the people involved, and yes, there is certain funding that is necessary.

Some of what I have to say today will be good. Some of what I have to say today will be bad news.

The good news-bad news is like the fellow, who as someone rushed into his office with some good news and bad news. The bad news was that his mercedes just went over the cliff and was totally destroyed. Well, what in the world was the good news? His mother-in-law was driving. Now all of us are aware in the administration of athletics and in the care of injuried athletes, that there are important trends that have been taking place in recent years. We set an increase in the number of those participating in athletics at all levels. Not just in college and high school, but even in recreational sports. We have seen pressures put on by many different groups, as they should be, to reduce the number of injuries.

At the same time, we have seen this increase, we've seen decreased funds available to fund these programs. We have seen an increased vulnerability to litigation and we've seen spiraling increased costs of medical care for these individuals. Now I don't need to talk to you about the increased number of athletes. We've seen it certainly in the colleges and in high school. These are staggering numbers when you take a look at them.

We have seen pressure to reduce the injury rate. More than one million sports-related injuries per year, more than 111,000 serious injuries and more than 60,000 surgical knee procedures get carried out as a result of football each year. I don't need to talk to you about decreased school budgets. You are much more aware of that than I am because you are constantly undergoing a fight to obtain the funds necessary. Much of what I have to say today relates to increased vulnerability and litigation due to lack of informed consent, and also due to negligence. We have seen increased medical costs. A 20 percent increase per year compounded, and if you have not gone back lately and looked at the increased costs for your insurance, they have spiraled. Anticipate what you are going to do to pay those costs in future years if they continue to spiral at the same rate.

The good news is that we have seen a trend which is a very definite trend to fewer football fatalities. In professional football, there were nine deaths in 1964 and some of those nine with the high school athletes. Last year we had three heat stroke deaths, all of these in high school players. This indicates good programs for the prevention of heat illness with our college athletes. You are to be commended for the efforts that you put forth for the past 20 years. Head injury deaths in 1984 were only six. Permanent paralysis in 1984 were also only six. In the early 70s, we had an average of 36 deaths per year, so we are down to nine in 1984. You are to receive the credit for that reduction. In the early 70s, we were hav- ing 40 quadriplegics a year, relative to sports participation in the organized level in football. In 1984, we had only six. Again, this is good news. This decrease in fatalities has been brought about by the efforts of your profession, my profession and with improved helmets and the 1976 rule change against spearing. But, even though we have seen a decrease in the fatalities, even though we have seen a decrease in the paraplegics, even though we have seen the tremendous decrease in the number of heat stroke injuries and deaths, we have seen a tremendous increase in the amount of liability to schools, to districts, to individuals, to the medical profession and to almost everyone who has anything to do with the care of the athlete. Most especially, with equipment manufacturers. Twenty years ago there were 17 manufacturers of helmets in the United States. Of those 17, only four remain. And this is due loo percent to the high litigation rate that they themselves have had to support. So while your profession and my profession have been doing a tremendous job at reducing injuries, particularly the serious injuries, other legal professions, lawyers, have been doing everything they can to find ways and means to create chaos among the athletic programs.

Legal problems relate to two primary areas; the failure of informed consent and negligence. The failure of informed consent is simply not letting the athlete know that they might be hurt. They may be paralyzed and they may be killed. You must tell the athlete that and have it in writing that he understands that. If he is not 18 years of age or older, in some states where they are still minors until 21, then you must have the parents acknowledge that they know. One simple document will actually take care of one of most common causes of litigation in athletics at the present time.

The second one is not nearly as easy to take care of. It involves negligence; not doing what a prudent individual would do under given circumstances. Not doing what is customary. Not doing what is known. The fact that you are a college, maybe in the sticks, a long way from the metropolitan mecca, no longer excuses you from not doing just exactly what they might do at Notre Dame or at North Carolina or at Ohio State. They may have more personnel, but nevertheless, their liability is no greater than yours wherever you might be. Failure in form consent is very important and negligent. Many things that we are going to talk about relate more to negligence. Now we said there has been a tremendous increase in the number of litigations and the number of awards. I'll take just a few; 1981, Oregon, $1.8 million; 1982, Seattle school district, $6.4 million, later appealed and over one million awarded; just recently, the State of California, $15 million. You know who took the brunt there, the helmet manufacturer. You mark my word, in the future it's going to be less and less on the equipment manufacturers and more and more on the schools and the personnel involved in the schools.

At the present time, there are more than 75 serious injury cases pending in the courts, with a potential liability greater than $100 million. If all of those are settled, what is that going to do to athletics as we know it at the present time? What are some of the things that give us liability exposurE Supervision in administration, equipment and facility, the medical aspect, travel and transportation, activity preparedness, that is participation evaluation, many many different things. You as athletic directors have to be concerned in that particular area, as it relates to due process, free speech, sex discrimination and so forth. What are the roots of liability? Ignorance of the law, ignoring the law, failure to act, failure to warn, and expense. There may be some of you who don't realize that if you alter the helmet in any form, Lt must be recertified before it's used. So, if you allowed a player to play who had that helmet on that was not recertified, then you would fall into this category of ignorancl of the rules and regulations of the laws as they exist to participation in football.

Item two is ignoring the law. A good example of that would be allowing a coach under your charge to be teaching tactics such as spearing, butt blocking, butt tackling. Your peers passed a rule in 1976 that made this unlawful. For years the medical profession has said you should not do it, but in 1976 COi said you should not do it. So, if this is allowed to go on in an institution, then you are ignoring the law. Failure to act. Knowing you should do something but failing to do it. An example of that would b, not requiring that an athlete wear the required pieces of protective equipment; for example, the flexibll mouthpiece. Not letting the athlete know that he might be seriously injured. Now remember, while I'm talking today, I'm talking predominantly about football, but each and every risk that we talk of in footl exists in other sports too. And to some degree, even greater because at the football game, most of you have doctors. At the football game, most of you have certified athletic trainers. But how about the baseball team that may go for a week. Who is the trainer? Is he a certified trainer? Is he a student trainer? Who goes along with them and what medical care is going to be taken? They can have serious injuries as well.

The purpose then of this program that we are outlining is to reduce to the lowest possible level, t risk of injury and to provide optimum care should injury occur. You should also reduce the likelihood ( liability and to reduce the cost of medical care. What are some of the preseason guidelines that we mul be concerned about? We are going to be talking about the importance of meetings and communication of e, one involved with the program; the coaches, the medical personnel, the parents and the athletes. At thl high school level it is essential that the parents be talked to. At the college level it is desirable j most and essential for those who are under age 18. To establish a health plan, what are we going to do~ How can we improve it? What are the problems that we have existing now? The doctor will have this responsibility. The athletic trainer will have this responsibility. The coach will have this responsibility. Suppose a player goes down on the field. Whose responsibility is it to make the evalu. while he is on the field of play? Is this going to be the trainer? Is it going to be the team physici. Is it going to be the orthopedic surgeon? Who will make these decisions at that time? Communication ii very important, and the spelling out in writing of the responsibilities of these involved people. We h~ to establish a medical care system. Have an emergency calling system. Equipment, supplies and facilit all need to be evaluated and then we have to have a method of financing this. The day and age of some institutions allowing people to play who do not have insurance is totally gone as far as I'm concerned; all levels of participation, not just in colleges where they are more affluent, but in every college. must be means before the season ever begins of taking care of the medical care involved in conducting tl athletic program. If in your institution you do not have adequate funds, you should not be putting a gi on the field.

Now, what does a team consist of from the medical standpoint? The team physician, the team dentis the athletic trainer, and various specialists that might be needed. The team physician has to establis health guidance, policy, procedures, be present at the contests, available during practice and be able make medical judgements when necessary. He has to hold the interest of the individual as well as the tea individual is first, not the team, not the coach, not the athletic director. Knowledge of medicine, a willingness to give time and a desire to further public relations are minimum essentials for the team physician. These apply to the other people on the medical team, whether we are talking about the athletic trainer or others.

We have to understand the individual. We have to know him well enough to establish a norm, know something about their general behavior, their capabilities, their problems and their interests. Some athletes only have problems when they fail.

The physician's first concern is prevention of injury. That means he has to be involved with what is going on. Not just there for the event, but in the planning stages, so that they can do things that are necessary to prevent these injuries. The team dentist conducts preparticipation dental exams, arranges for emergency medical dental treatment and is responsible for the mouth protector program. Administrators, I hope you know that these things we are saying relate to administrative detail. Do you have this type of program, type of personnel? Do you have this type of training? Are you taking these assessments of what you have going on? Do you know these things at the present time?

The same is true for the coach. The coach must improve the injury recognition skill because the coach, many times, may be the one who has to make a decision of whether they can continue to practice or not, or whether they go to the sidelines to see the trainer. We must have detailed records of all injuries and what is done for those injuries. Every coach in America today should have certified cardiac respiratoryr~$Us~itationtraining, certified. They should all have first-aid certification. These are minimal to enhance the competency in the medical aspects of sports. The athletic trainer works with the doctor and assumes most "of the duties of the doctor when the doctor is not there. If you have athletes under the age of becoming legal adults, then you must have permission signed in advance for emergency medical treatment. You must present a plan for medical emergencies and care. What are you going to do in case an athlete is injured? The participation evaluation relates to the health history of the physical examination, both static and dynamic, and these are becoming more and more sophisticated.

Heat stroke, as I've said, is a preventable death, 100 percent, if the appropriate measures are taken. What are these? Acclimatization to the athlete and complete physical evaluation. Acclimatization is done gradually over the first 7-10 days of the conditioning program and recording temperature and humidity hourly. Adjust the activity according to the temperature and humidity. Provide rest breaks periodically. Give them water unlimited, always available. Provide salt at the table, salt tablets and salt solutions. Weigh the athlete before and after practice and games. Any weight loss greater than three percent should be considered serious. Any weight loss over five percent should be enough evidence to keep that individual out of practice until he has regained that weight loss. Provide proper clothing, loose, lightweight and light color. Observe the athletes closely for signs of heat illness and protect them.

What are some of the other preseason plans that are very important? Preseason work out programs. Be sure that the ingredients of the program are proper that you include all the components of the strength, the flexibility, the aEroBics, the speed, the agility, the reaction, the balance, the coordination, relaxation. All training components should be an integral part of the overall conditioning program. Then you must emphasize also the general health measures, the nutrition, the drug use and abuse and the proper amounts of rest and relaxation. The athlete needs to know the basic needs of his nutrition and he must know any special needs.

One of my former athletes at Georgia Tech. in the premouth-guard era after receiving an uppercut blow to the jaw. multiple injuries and concussion. nearly died. Simply wearing a fitted flexible mouthpiece would more than likely reduced the severity of the concussion. would probably have prevented the fractures from occurring and would have prevented this guy from even being hospitalized. instead of being in the hospital near his death.

We have already told you that injuries to the head and neck are the most frequent injuries that kill and paralyze the athlete. A study done in California indicated that 75 percent of the serious head injuries were to those who had improperly fitted helmets. Only five percent of those having serious head injuries wore a helmet that properly fit. Simply properly fitting of the helmet can significantly reduce the likelihood of having a serious head injury to your athlete. Blocking and tackling techniques still must be taught the correct way.

The intelligence of the athlete, the ability for the athlete to comprehend what the coach says, the x's and o's are getting more and more complicated, and if he doesn't comprehend, he can't execute, and if he doesn't execute, then he may be inj\ured. We are doing some studies now as the relationship of lack of concentrat~on to injury. We know that just as automobile accidents, just as home accidents are caused by lack of concentration, we know that athletes are hurt because of lack of concentration too. Many times the lack of concentration relates to the poor understanding of the task they are being asked to do. If you have somebody onthe team who has only been participating in football for a short period of time, he should not be placed on the drill up against the biggest, most talented athlete that you have.

At Georgia Tech, even though we are in the ACC and most of the schools in the ACC have medical centers, we do not rely upon that school to provide us with the neurosurgeon if we have a serious head injury. Before the season, a letter goes from our neurosurgeon into every community where we play and a neurosurgeon agrees to see our athletes. It is not a happenstance situation. We have it in writing, in advance, from our neurosurgeon to their neurosurgeon.

Female participation is probably three hours and would be a minimum that we should undertake to talk about. We see more girl basketball players with knee injuries than we do boy basketball players. Serious injuries, and this is not just at Georgia Tech. This is not just us in the metropolitan Atlanta a~ea.

This is the trend throughout the country. So, we have to recognize some of these things. There has to be a reason why this is true. We must address these reasons and do what we can to protect these girls in that circumstance.

Just a word about cheerleaders. You thought we were just going to talk about football. But we cannot neglect the cheerleaders. In a relatively short period of time we have gone from a group that encouraged the spectators to cheer, to a transition to another group of athletes. Athletes who are performing daily and doing things that are just as dangerous as any football player, any wrestler, any other sports participant.

One other area that is o£ten totally neglected is transportation. The competency 0£ drivers, the sa£ety 0£ the vehicles and adequate insurance. Sure, you make good arrangements £or your £ootball team, but what happens when your gol£ team goes somewhere? Who drives that car? Is it one 0£ the players? Is it one 0£ the students? What car does he drive.

Athletics provide numerous opportunities for personal growth and stretching forth the limits of our human potential. The desire to excel, to obtain high standards of performance, to do one's best is certainly a worthwhile ambition and one that we would like to encourage. However, unless we can reduce the frequency of injury, unless we can reduce the cost of medical care for the athletes, unless we can do something to reduce the high and ever-increasing risk of litigation, unless your profession and my profes! do something soon, then our grandchildren will not likely have the same opportunities that we have enjoye~ in our search to excel and attain the high standard performance. Because unless we do something and unless we do it soon, litigation will so change the face of the athletics that we will not recognize them as they have been in our lifetime. Thank you very much.

KIT GREEN:

As you can tell, Fred had a great deal to share with us. We do have a few minutes left to have a question or two. I have a question I would like to ask Dr. Allman. When you have coaches who receive reports from the training room and the physician and ignore those recommendations relative to practice, kind of situation will they find themselves in?

FRED ALLMAN :

I know I've been faced with this where coaches really don't want to take the advice of those in the training room, relative to practice. Particularly, they don't want to hold them out of practice. Perhal they have been told in a track situation that they should be doing slow workouts rather than sprinting al full speed. What kind of implications does that have for that coach and for the administration? I thinl the answer to that is, what is the procedure and policy in the given institution? These things need to stated in advance, put in writing.

BARBARA HOLLMANN :

Let's take that one step further and place the student-athlete in the position of receiving the recommendation from the training staff that he should do such and such, and he fails to or they continue to go to practice and do not adhere to what the athletic trainers have told them to do, or suggested the, should do? Is it exactly the same thing?

FRED ALLMAN :

What is the policy and procedure in your institution? Has that policy and procedure been carried If not, someone is negligent. Who is negligent if there is no policy and procedure? Stand up ladies ; gentlemen. This is the whole point that I am trying to make. If these procedures, if these policies ; not in writing, if you do not have any in your school, then each and everyone of you are responsible for that.

LEO MILES

What do you think about the physician or the trainer who assesse,s the injury and then asks the kid, "how do you feel. Do you feel like you can play?" Sometimes the trainer would take the advice of the student- athlete.

FRED ALLMAN :

Well, there is nothing wrong with the question, if there is a fallacy there, it is the experience in judgement of that person asking the question. Always, before I let a player go back in I ask him how he felt. I might check him and find something is wrong. It may be mental, it may be physical, but if there is something wrong, I don't want him back out there. By the same token, my judgement may not be 100 percent at all times, so I want to know the feeling of the athlete. I want his verbalization of how he feels about his injury. Now, recognize that many of these people are going to try to pull your leg to go back, and you know good and well they can't.

Let me give you one other example of how things go and how the tables turn. When the Georgia high school all star football game was played in Atlanta for a number of years, I had the major responsibility in the conducting of the medical care at the game. On the opening kickoff, we had a running back who received the ball and ran up the field and was hit. As he was falling forward he was hit on the head by the knee of a lineman coming right at him. You heard this thud for at least a mile and everyone in the stadium heard it. He was rendered totally unconscious. We stopped the game. We were in no hurry to move him. We evaluated him carefully. After about five minutes, he regained consciousness. We removed him to the sidelines and we continued to evaluate him. Everything progressively cleared. Before we got the kid to the sidelines, the parents came out of the stands asking us how badly he was hurt. Why don't we take him to the hospital? Why wasn't the ambulance there? The ambulance was there, but we did not see fit to evacuate him to the hospital at that time. We wanted to evaluate him and we couldn't evaluate him when we sent him to the hospital. So this parent is standing on my neck telling me I'm not doing enough. Well, this kid improved so much, that at halftime the same father who was getting on my back because I didn't send him to the hospital, wanted him to play in the second half. He satd this is the only kid in this high school who has ever been in this all star game. He's only been in one play. He said, "I demand that you let him go back because he is fully recovered." I said, "I have to make that judgement. You don't make that judgement. He is not going back in this game."

Well, he continued to periodically come down and tell me how good his son was doing. To make a long story short, we did evaluate him after the game. He did look clear. We allowed him to go home and told him we wanted to see him the first thing the next morning in the hospital. This kid had cerebral spinal fluid coming out of his nose the next morning. He was that close to having a very, very serious injury. The point I'm making is, people can be very, very fickle, and the same parent who is encouraging the team physician to allow somebody to play with an injury where they should not, or the same coach who is encouraging the team physician to allow somebody to play, may by the same people who turn around and say, "you are the one that should have said no." If you make proper judgements, most of the time you will do a good job, but there again, that's where the mileage comes int.

KIT GREEN:

We have run out of time. Dr. A1lman has a few minutes and will take questions up in the front. We want to thank all of you and thank him for his presentation.