Concussion and the GAA doctors’ dilemma

The opening weekend of the Division One season threw up two concussion-related incidents. Ironically the one which was actually diagnosed saw Mayo's Evan Regan carted off immediately and without fuss whereas the one which wasn't created a controversy.

Tyrone manager Mickey Harte referred to Seán Cavanagh playing on for almost an hour with "mild concussion", because, "after some deliberation with the medical people he decided he wanted to stay on and it wasn't serious enough for the medics to have to take him off".

The GAA has put a fair bit of effort into educating the membership about concussion but phraseology can sometimes be loose. Harte presumably didn’t intend to suggest that team doctor Elizabeth O’Hanlon allowed herself to be talked out of recommending that Cavanagh be taken off by the player himself.

O'Hanlon is secretary of the Gaelic Games Doctors Association and both examined the player and – because of the lengthy break in play caused by floodlight failure – was able to monitor him for even longer than would be the case in a normal match. Concussion – mild or otherwise – was not diagnosed.

In fairness to Harte it's not that he could be said to have a relaxed attitude on the issue. He had omitted a player, Peter Harte, from the Monaghan match because of a bang to the head he had sustained in the McKenna Cup final.

In Mayo’s case the controversy arose because although the player had been taken off with concussion, he had also sustained a fractured clavicle and a cut lip, which allowed the team treat the player as a blood replacement and protect the integrity of their six-strong substitutes’ list.

Stretching the definition

They were given the green light on this by the fourth official and so there was nothing irregular about the designation even if it has generally been portrayed as stretching the definition of temporary replacement beyond even fanciful concepts of elasticity, especially given that the

Official Guide

terminology is “temporary substitute”.

Yet looked at from a medical point of view, such situations appear very different than simple opportunities to pull a fast one. Treating injuries on the field and deciding what to do in the space of a minute or less doesn’t leave much time for nuance and availing of blood substitutions can buy time.

Obviously a broken clavicle isn’t a matter of nuance but concussion frequently is. Team doctors don’t always get to see television replays of an incident, which could draw attention to the seriousness of the injury and its potential to cause concussion. A player takes a hit but exhibits no immediate signs of impairment. What do you do?

If you suspect concussion there’s no mechanism to withdraw a player for investigation without using up a replacement. Obviously that’s an easy call if it’s a clear-cut case but if it’s not?

Mayo found themselves in the middle of a high-profile episode of that last summer when there was a clash of heads between Cillian O'Connor and Aidan O'Shea in the All-Ireland football semi-final replay.

Recalling in an interview last month that he had been “groggy” and not “100 per cent”, O’Shea – presumably like Harte at the weekend, unwittingly – gave the impression that he had been allowed back onto the field with concussion despite having been cleared after observation by the one person qualified to do so.

Go-to experts

The Mayo medical officer is Dr Seán Moffatt, according to the GAA’s Medical Scientific Welfare committee, one of their go-to experts on concussion.

Last September in the aftermath of the Kerry-Mayo match he appeared with Dr Barry O’Driscoll, who has campaigned on the issue of concussion in rugby, on RTÉ radio and detailed for Seán O’Rourke how, because of the players’ facial injuries he had detained them on the sideline at the start of the second half for further observation and tests.

“Only when I was satisfied that there was no concussion were they let back,” he said. “That’s the duty of care we have towards players.”

It can be an intolerable position for team doctors. They have to make almost snap diagnoses. In an amateur game they’re not on the payroll and have their own medical practices but are frequently seen as part of the team despite this potentially compromising perceptions of their professionalism.

Seán O’Rourke put his finger on this when querying did Moffatt in a sense have a green-and-red jersey on when tending to the team. The reply was emphatic.

“If you are a sports and exercise physician and you’ve done the higher training, no matter what’s happening in the game you have to separate yourself from the emotions of the game. These were two players under my care that – I would have been acutely aware of sports concussion – I felt if I let them back on the pitch when they were in a vulnerable position for a second impact I was putting their health and safety at risk.”

“So you must, must, must separate yourself from the emotions of the game. It was a facial injury but with my knowledge of concussion I had to satisfy myself.”

Team doctors could be the only people in the GAA who envy referees. smoran@irishtimes.com