The Sports Medicine Team – PediaCast 332
- Guest Host Dr Eric Bowman joins Dr Mike, along with Dr James MacDonald and Athletic Trainer Gail Swisher. Our topic this week is the Sports Medicine Team. Who are the folks who care for your kids on the playing field? What kind of training do they have? How do they decide what sort of treatment your child needs—a bandage on the sidelines, an urgent care trip, the emergency room, your regular doctor, or a sports medicine clinic? And speaking of the clinic, who works there? What roles do they play? And what can you expect from a visit? If your child plays sports… or plans to play sports… it’s an episode of PediaCast you don’t want to miss!
- The Sports Medicine Team
- The Sports Medicine Clinic
- Sports Medicine Specialists
- Certified Athletic Trainers
- Caring for Student Athletes
- Dr James MacDonald
Sports Medicine Specialist
Nationwide Children’s Hospital
- Gail Swisher, AT, ATC
Certified Athletic Trainer
Nationwide Children’s Hospital
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children’s, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello everyone, and welcome once again to PediaCast. It’s a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children’s Hospital. We’re in Columbus, Ohio. It is Episode 332 for November 5th, 2015. We’re calling this one “The Sports Medicine Team”.
I want to welcome everyone to the program.
So, the ever popular and occasional guest host, Sports medicine specialist, Dr. Eric Bowman joins me again today. He brought along two other members of the Sports Medicine team — Dr. James MacDonald, who is also no stronger to PediaCast, and athletic trainer, Gail Swisher — to talk about the Sports Medicine team.
We’ll get to exactly what that means in a moment. I say ever popular because these special edition sports medicine episodes of PediaCast have seriously rocked in the download department. They’ve been full of great relevant and practical content, and you the audience had eaten them up, which is appropriate given that the last one was on sports nutrition.
Dr. Mike Patrick: Like I did that. I know, I can hear some of the groaning out there.
So what does the discussion on the sports medicine team look like? Well, there’s sometimes confusion about the folks who take care of your kids on the playing field. What’s the role of the team doctor versus the athletic trainer? What unique skills does each possess? What sort of training do they receive? And how do they decide what sort of treatment your student athlete needs?
Does your son or daughter simply need a bandage on the sideline or a trip to an urgent care center? What about an emergency room visit? Or, maybe see your doctor the next day or sports medicine clinic visit?
Speaking of the sports medicine clinic, who works there? What do they do? If you go for a visit, what can you expect?
So it’s another informative and practical sports medicine edition of PediaCast. Before we row with that, I haven’t talked about the 700 Children’s Blog in awhile. In fact, it’s been so long we probably have a number of new listeners who have no idea what I’m talking about. There are plenty of health blogs out there. Nationwide Children’s health blog is pediatric-specific. We write about a wide range of topics. We provide content that’s in-depth, but not so long you get bored. It’s in a language that parents can understand.
And, here’s the cool thing. We don’t have one writer. We really call on the collective expertise of our entire institution and find the best writer for the topic at hand.
Where will you find this digital gem? It’s at 700Childrens.org.Pretty simple, right? But just in case you forget, I’ll put a link to it in the Show Notes for this episode, 332, over at PediaCast.org.
Why 700 Children’s? Well, that’s been the address of our hospital, 700 Children’s Drive, for about as long as anyone can remember. We thought it would make a great online address as well. So, 700Childrens.org.
Recent topics to read and share with your family and friends: Indoor Activities for Kids When the Weather Gets Cold, When Kids Draw Violent Pictures, Should you Worry?
Does the Sight of Blood Make Your Child Feel Faint? That one written by yours truly in time for Halloween, which I know has passed, but it’s still a good relevant one.
Pierced Ears — How to Prevent Painful Infections, Top 12 Tips to Give Relatives who are Babysitting for the First Time, Spleen Injuries in Sports — What Parents Need to Know. That one written by another of our sports medicine specialist, Dr. Steven Cuff.
Growing Pains… Are They Real? Teens, Birth Control and “The Talk”… What You Need to Know. If you’re interested in that one, be sure to check out last week’s show on talking to children and teens about sex.
Another one, The Importance of Tummy Time, How to Talk to Your Child About Differences, Universal Newborn Hearing Screening, and The Parent’s Guide to Pink Eye – also written by me.
See, my office is closest to the director of our blogs, so she may or may not be prone to a bit of arm twisting. But really, I’m happy to do it.
So, please check out the Nationwide Children’s pediatric blog. You’ll find the topics I mentioned and many, many more again at 700Childrens.org.
All right, a couple more quick items of business before we get started. Please remember that this your show. So, if there’s a topic you’d like us to cover or to talk about, if you have a question for me, you want to point me in the direction of a journal article or a news article that you’ve seen, it’s really easy to get in touch. Just head to PediaCast.org and click on the Contact link.
You can also call the voice line at 347-404-KIDS. 347-404-K-I-D-S, if you’d like to leave a message that way.
Also, remember, the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child’s health, make sure you call your doctor and arrange a face-to-face interview and hands-on physical examination.
All right, let’s take a quick break. We’ll be back to talk about the Sports Medicine team, and our guest host would be Dr. Eric Bowman. That’s coming up, right after this.
Dr. Eric Bowman: All right, well, thanks again, Dr. Mike, for that intro. I really appreciate it.
Hey, everybody out there. Hope you guys are all doing well. Glad to be back here on PediaCast bringing you some sports medicine topics and information. Again, I just wanted to say thanks to everybody who’s been listening and downloading. I know, as Dr. Mike already said, this is your show. And that’s we really want to make sure you understand, is that we have topics that we can cover but we want to know what you want to hear about.
So, if you’re interested, please just make sure you’ll let us know and we can certainly try to talk about some of the things that you want to know about when it comes to sports medicine.
Dr. Mike Patrick: That will be a great one, actually, if we had people write in questions and keep a collection of them and just cover those sometime.
Dr. Eric Bowman: I love it. That’s great. So write them up, bring them in. Let us know what we can do and what we can cover. We want to make it your show.
As Dr. Mike already mentioned, I have two guests with me here today. I have Gail, who is athletic trainer at one of our local high schools, here to help us out today. How’s it going, Gail?
Gail Swisher: Good. How are you?
Dr. Eric Bowman: I’m doing well. Thank you.
The great thing is we also have Dr. Jim MacDonald with us, one of my colleagues. The great thing about Gail and Jim is they both work at the same high school. So that’s going to bring an interesting perspective to our talk today.
So Jim, I want to say thanks for coming and joining us.
Dr. James MacDonald: Thanks Eric, and go Bexley.
Dr. Eric Bowman: That’s right. You guys are doing pretty well this year, yeah?
Gail Swisher: So far, so good. Big games this week.
Dr. Eric Bowman: OK, we’ll see. We’ll see.
All right, well, the topic of today’s PediaCast is really just kind of to get a chance to look at the sports medicine team and how your child is taken care of, and who’s taking care of your child, and what part of the process is.
I know it can sometimes be a scary thing to go through, when you see your kid go down the sideline. We just want to kind of let you know who we are and what we do and what our training is, and what our background is and those sort of things. So that’s what we’re going to try to bring with you here today.
To just kind of jump in and get started, I want to start with Gail and kind of talk about the role of the athletic trainer. I think a lot of times, people may or may not realize, but the athletic trainer is that first line. They’re usually the person who we typically see right there on the sidelines or see in the kids at the schools or whatever level they may be.
I think one of the first questions starting off is, what is an athletic trainer?
Gail Swisher: What is an athletic trainer?
Dr. Eric Bowman: Yeah, I ask you.
Gail Swisher: So we are healthcare professionals. You find us in a variety of settings. But we work with physicians. We collaborate with physicians to deal with injuries and illnesses of people who are physically active. So, that can be athletes, or that can be weakened warriors or that can be anyone who is physically active in their life.
We specialize in things like prevention, emergency care, clinical diagnosis, therapeutic interventions and treatments and rehabilitation of all those injuries and conditions sustained by people who are physically active.
Dr. Eric Bowman: So, I guess my question is, do you do that under your own authority? Are you your own person? Are you under supervision? You may hear phrases like “under the direction of” or “collaboration with the physician”. What does that mean?
Gail Swisher: So it varies a little bit from state to state based on your state licensure laws, but we do collaborate with physicians. So that means we have some physician over site. They are not necessarily right next to us all the time. Dr. MacDonald and I, you’ll find us together on Friday night on the sidelines, but the vast majority of the time, I’m at the school and he may be in the clinic. But the communication lines are wide open. So email, calls, things like that, so we can bounce ideas off one another and we can kind of work in two separate realms.
Dr. Mike Patrick: I like what you said about bouncing ideas off one another. So there’s sort of this assumption that the physician knows everything and that the athletic trainer may need to work under the supervision of a physician, but really there are lot of things that athletic trainers know that the physician isn’t really in contact with day in and day out, and just an enormous resource for doctors.
Dr. James MacDonald: That hands-on deep relationship that the athletic trainer makes with almost all the athletes under his or her care is invaluable. It’s something that a physician just can’t bring to bear. So, an athletic trainer, oftentimes, is that person who will really know — sort of just like Doctor Mom — really knows when their child’s ill. The athletic trainer can really make that diagnosis a lot of times a lot better than the physician.
Dr. Eric Bowman: And I think it’s really important to understand that because a lot of times, you may hear a parent say, “Well, what does the doc say? I want to see the doctor,” and that sort of thing. I think it’s really important to understand that you know the kids. And, as a physician, we try to get to know all of our athletes in our teens, but it’s just we’re there usually one game a week, right? And it doesn’t happen, and so that’s why the athletic trainer such as I were part of our team, the whole topic for today of how that process works.
Gail Swisher: I think that’s one important things that athletic trainers bring to the table, is that they know when they can treat kind of remotely from the physician, as well as when it’s time to refer to the physician and what type of physician they need to be seen by. So that’s one of our roles in settings like schools.
Dr. Eric Bowman: So, again, that’s first line right there in the trenches per se, right?
Gail Swisher: Right.
Dr. Eric Bowman: All right, good. Well, my question is, to be an athletic trainer and to be able to have that job and have that role in the school, what do you have to do? What do you have to go through? What kind of training and education or certification, those kind of things?
Gail Swisher: So we have to have a bachelor’s degree that has to be from an accredited institution and there’s an accreditation standard under a national governing body. But, you have to complete a program that includes some clinical hours where you do hands-on work under the direction of a certified athletic trainer. And then, at the completion of that program you can sit for a national certification exam to become board-certified as an athletic trainer.
And then, subsequent to that, each state has its own licensure law which is a little bit different, so you have to apply or potentially test for a license in whatever state you’re going to be practicing in.
Dr. Eric Bowman: So it sounds like there’s a lot of education as part of this and national certifications and testings and very standardized, at least as far as the basics of the education goes.
Gail Swisher: Absolutely. So there’s a lot of different domains that we have to learn about, whether that’s injury recognition or treatment, rehabilitation. We got a lot of work in the sciences, anatomy, physiology, things of that nature to prepare us for the clinical hands-on aspect where we can actually apply that knowledge in the field in real life settings.
Dr. Eric Bowman: So that leaves me right to my next question of, I hear people say, “Well, what’s the difference between an athletic trainer and a personal trainer? Is there really any difference at all? Can I just go see a personal trainer instead of my athletic trainer?” What’s the difference there and is there one?
Gail Swisher: There is absolutely a difference. Athletic trainers do get some training in working out, physical fitness, things of that nature because that does fall under the healthcare realm. But personal trainers have varying certifications. So it may be something as simple as a weekend course. It may be something more extensive, such as strength conditioning certification.
But we have different skill sets. Athletic trainers like myself, we work with injuries and illnesses. Whereas, personal trainers are more the person you’re going to go when you’re looking for a workout, maybe to lose weight, gain weight, general fitness, things along those lines. So we do function differently, and if you have an injury or healthcare needs, I would encourage you to seek out an athletic trainer versus a personal trainer.
Dr. Eric Bowman: So, nothing against the personal trainers in the healthcare industry in getting people stronger, just not necessarily the best option maybe for the recovery and the rehab and that sort of thing.
Gail Swisher: Correct. We’re just two different folks with two different skill sets, and if you work within each realm appropriately, you’re going to get the best outcome.
Dr. Eric Bowman: Perfect. I mean, I think that’s a great way to explain it.
Well, you said work within different realms and different locations and different things. Where do athletic trainers work? We’ve obviously discussed the high school. We know that’s an option, but are there other locations? Are there other places, are there other things that athletic trainers can do other than just work the sideline on a Friday night?
Gail Swisher: Yeah, there are lots of places you’ll find us and some of them are surprising. So, high schools and middle schools and even now, trickling down into youth sports, which is a great thing.
You’ll also see us in colleges and universities, in athletics, professional sports, places like the Olympics, with dancers. We actually have an athletic trainer on staff who works a lot with dancers, and that’s her area of expertise.
You’ll also find us in places like industrial medicine. So perhaps, workers who are on an assembly line, who are physically active all day long, athletic trainers can help those folks as well.
You’ll also find us in the military, since military personnel do get injured. So, really, anywhere you have someone who is physically active, you may find an athletic trainer.
Dr. James MacDonald: Can I jump in for one second?
Dr. Eric Bowman: Absolutely, please.
Dr. James MacDonald: I want to also say, you’ll also find athletic trainers in academia. There are two things I want to pass on to listeners. One is, one of the premier sports medicine journals in our field is The Journal of Athletic Training. Some of the most cutting-edge research specifically in the injury of concussions is coming from the athletic training community.
I can think of one person that everybody, that I’m looking at right now, has heard of — but maybe it’s a new name to the audience — is Kevin Guskiewicz, from University of North Carolina, an athletic trainer who just two years ago won one of the McArthur Grants, the Genius Grants, of $100,00+ for his research on concussion. And he’s not unique in the athletic training field.
So there are also leaders in pure research and academics. It’s quite impressive.
Dr. Eric Bowman: Absolutely. I think that’s what’s important to understand, is that again a lot of times, people just say “Oh, they’re the person on the sideline,” but they’re so much more to what we do in sports medicine. They’re a foundational part of what we do here.
I think it’s important for everybody out there to understand their roles, not only from what you can see but behind the scenes, like you mentioned with the research and just the knowledge growth and everything that’s out there. So, absolutely, that’s really good to know.
Gail Swisher: There’s a lot that you don’t see with athletic trainers beyond the sideline. The time that they spend in the athletic training room, doing evaluations, doing rehabs, talking to parents, talking to coaches, things like that. That’s where the real nitty-gritty of the work gets done.
Dr. Eric Bowman: So they don’t just work for the hour and a half of a game or the three hours of the football? You mean that’s it?
Gail Swisher: No, that’s not quite how it works out.
Dr. Eric Bowman: A little more than that, huh? OK, all right.
Well, one of the things you guys mentioned earlier is that how you have that communication, and Dr. Mike talked about communication and that sort of thing. We obviously discussed that’s one of the important components of a sports medicine team. What do you think is another important component? What are some other things that are really good to have back and forth to make that sports medicine team work the way it’s supposed to? What things do you have?
Gail Swisher: I think clearly defined expectations are key, and that’s a matter for each sports medicine team to figure out what’s the comfort level here? How often does the AT communicate with the physician? How often does the physician want an update on a certain athlete? How do you go about getting an athlete in to be seen for X-rays and evaluation in an emergency?
So figure out these things ahead of time so that you know when you’re in an emergency stressful situation, here’s how it’s going to go down and you’re not trying to figure it out on the fly.
Dr. Eric Bowman: That sounds great and it’s really good.
All right, you’re not going to be done yet, Gail, but I just want to ask one last from the athletic trainers perspective here. Give me take home messages, anything you like, “I want the people to hear this about athletic trainers.” We had a lot of valuable information so far, but what’s one thing, like “What’s my take-home message?”
Gail Swisher: I would say the parents, if you have an athletic trainer at your school, talk to them, get to know them, know who they are, figure out how they operate, what the best way to get a hold of them is and utilize them as a resource. Because we are available the vast majority of the time, and we can help you figure out, does your child need to go to urgent care? Do they need to go to the emergency room? Can we may be treat this here at school or what other physician they may need to see and what kind of rehab they may need to do at the school?
I would say just get to know them and let them be your guide and your resource.
Dr. Eric Bowman: So, they’re a tool. They’re your friend. They’re there to help.
Gail Swisher: They’re absolutely your friend. If you don’t have an athletic trainer on your sideline or access to one, I would encourage you to ask why. if you’re at the school and your kid is playing sports and there’s not an AT there, why not? And, is that something that you could make happen in the future?
Dr. Mike Patrick: Do you see athletic trainers working with marching bands?
Gail Swisher: I do see band kiddos in my office. I know them too.
Dr. Mike Patrick: I see more band injuries this fall.
Dr. Eric Bowman: True.
Dr. Mike Patrick: So far, just a ton of them.
Dr. Eric Bowman: Yeah, absolutely. I know they do a lot of marching and spend time…
Dr. Mike Patrick: A lot repetitive motion kind of injuries.
Dr. James MacDonald: Some published data, about one third of American high schools do not have an athletic trainer. I just want to echo what Gail says. Sometimes, it comes down to financial constraints, but ask why. Because this data is published, if you have an athletic trainer at your high school, injury rates go down. Diagnoses of concussion go up. In other words, recognition whether somebody has concussed goes up. The ability to take care of heat illness, for instance, is improved.
One study has shown, high schools without an athletic trainer, re-injury in soccer players is six times greater than in high school with an athletic trainer. In other words, their ability to do the proper rehab is hands down better in high schools with athletic trainers than without.
So, if you’re out there and you don’t have an athletic trainer in school, ask, inquire why and see if you can make something happen in your school. It’s very important.
Dr. Eric Bowman: Absolutely. I think, Dr. MacDonald echo this as well. The athletic trainers that we work with are invaluable. They help our job. They provide so many things that we can’t, and we’re both extremely appreciative of the athletic trainers that we get to work with.
Dr. James MacDonald: For sure.
Dr. Eric Bowman: Absolutely. I want you to interject, Gail, on anything, as I talk to Dr. MacDonald on some of these other things. If there’s something else that you want to throw in there, please do.
Gail Swisher: OK.
Dr. Eric Bowman: You’re not on the sidelines yet.
Dr. Mike Patrick: There’s more groaning out there.
Dr. Eric Bowman: I know. I’m learning to be Dr. Mike, what can I say?
All right, Jim, I just want to talk about sports medicine physicians and some of the conditions and things like that in general. I think one of the big questions people may have out there is what is a sports medicine physician? What does that mean?
Dr. James MacDonald: Well, it’s evolved over time. But speaking about what it means in 2015, to be in the United States and nominated as a sports medicine physician, you have to go through a very specific training process.
Now, it begins with something called your primary specialty, and there’s a little bit of variance there. So, if you see a sports medicine physician in the United States, their original training is going to be one of five specialties. It’s pediatrics, internal medicine, family medicine, emergency medicine and physical medicine and rehab. All of those people have gone on to do a one- to two-year fellowship. That is, one to two years where they practice exclusively sports medicine. They learn exclusively sports medicine.
And then, the vast majority go on to sit for a subspecialty board exam called the Certificates of Added Qualifications. For instance, in Nationwide Children’s, I know you guys, you know this, every single one of us, I think there are eight of us, has done that. That fellowship and sat for a board specialty.
For instance, I’m looking at Dr. Bowman. I know he’s a pediatrician but he’s also fellowship trained and board certified in sports medicine. I’m family medicine fellowship trained, board certified in sports medicine as well.
So that’s the training aspect of what it means to be a sports medicine doctor in the United States.
Dr. Eric Bowman: So as far as the differences between the general pediatrician or family practitioner that you may see for your general conditions, it’s that additional training that usually sets you apart?
Dr. James MacDonald: Yeah. And, as ever, with additional training, one would hope and usually can expect a much higher level of sophistication and diagnosis and management. And some of it turns on, frankly, most graduates from primary care specialist bemoan the lack of attention to muscular skeletal injury in their training. I think it owes to they have so much that they need to learn to manage, for instance, very serious illness like in the hospital, in the ICU, hematology, oncology, you name it.
So, I think over time, the basics , which some says are showing like a third of people coming to primary care actually have a bone muscle joint problem, but those basis kind of get pushed aside sometimes in the curriculum.
So I think there’s a substantial difference in what most people can expect if they go to, for instance, their pediatrician and their son has low back pain and what they might expect if they come to a sports medicine physician.
Dr. Eric Bowman: Absolutely. I think it’s one of those things that we know that we’re trying to get that improved here at Nationwide Children’s. I know there are a lot of other training programs out there across the country who are trying to really improve the outcomes of muscular skeletal education and things like that as well. So something we want to continue to work on.
Dr. Mike Patrick: And individual physicians may have more of an interest and having taken the opportunity for learning experiences.
Dr. James MacDonald: For sure.
Dr. Mike Patrick: So, you may find a pediatrician who really feels comfortable following some things and some like “No, I want everybody to see sports medicine that way.”
Dr. James MacDonald: Just to continue a little bit of the theme of this talk, and I know our scope is to look at the team of athletic trainers and sports medicine physicians, but I think the nature of sports medicine is it is team work. And I frequently work as a team with the primary care doctor, and absolutely, it can be really helpful, that sort of give and take.
And, in awareness, sometimes, yes, I work with local pediatricians who go, “Jim, just run with it.” I’m cool with that. And that’s great. And then, others, they’re just calling me for a little bit of advice, “I can manage, I just want to make sure I’m staying within the boundaries.” We, frankly, do the same thing when we turn to some of the conditions we manage to hematologist for advice or pulmonologist and what have you.
Dr. Eric Bowman: Absolutely. I think that’s the great thing about medicine in general, is it can be that team approach and you can rely on each other. I think that’s a great point.
Well, the question now is you’re talking about managing this muscular skeletal conditions, so how’s a sports med doc different than an orthopedic surgeon?
Dr. James MacDonald: So, well, first of all, I think the figure around 90% of muscular skeletal injuries that present the clinics will be managed non-surgically. So the vast majority of injuries — the folks listening now — their children will get will be served in a non-surgical manner. Orthopedic surgeons can manage that as well. Frequently, they prefer for us to manage that because their time when they’re in the OR is surgery. So, their focus tends to be more surgical and their interest in surgical problems.
So that roughly 10%, if something where I see a knee and I identified it as an ACL rupture, I’m going to be involving my colleagues here like Dr. Kevin Klingele, “Kevin, I think I have surgical case for you.” But 90% of the kids are going to come in and don’t need surgery, and our training is specific to managing this non-surgically. I think that gives us a different world view and a different ability and success in managing those things.
And then, one final note, not everything we see is muscular skeletal. So, concussions, the classic, but we manage in our division, exercise-induced asthma. We manage, you mentioned the spleen injuries that Dr. Cuff wrote a blogpost about, sports anemia, sports nutrition issues. There’s a vast array of medical problems we manage in sports medicine. They’re not exclusively muscular skeletal. And it’s in our training. It’s just what makes it great.
Dr. Eric Bowman: Absolutely, and that’s good to know that your sports medicine physician has a broad experience in managing all kinds of conditions that are out there.
I guess that leads me to say what are some of the common conditions that you typically will see in a sports medicine clinic? What are the typical injury or other things?
Dr. James MacDonald: So speaking specifically the pediatric clinic, the focus that we’re all doing here, because it would different in an adult world, right?
Dr. Eric Bowman: Absolutely.
Dr. James MacDonald: Some of the big ones we’ll see, we see a lot of knee injuries. So we’ll see that ranging from chronic overuse injuries like Osgood Schlatter’s.
There’s a chronic condition that we see quite a bit of that’s mystifying to most doctors unless they focus in on pediatric sports medicine. It’s called osteocondritis disecante. We see that a fair bit in our clinic and if you’re in the outside world, it’s probably seeing you, and you’re not seeing it if you’re a doctor.
We see a lot of back problems. It’s really surprising. I was actually surprised in my training and in my experience here at Children’s to learn just how often young kids have back pain. I thought it was a problem of just me as a middle-aged guy, but it’s really remarkable.
We see all sorts of things ranging from stress injury called spondylolysis to disc problems to more benign things like normal sort of iPhone-type of back pain. You’re hunched over and back back backpain.
So back, knees, and I think concussion…
Dr. Mike Patrick: Speaking of the back, we have a great resource on back pain and injuries in student athletes.
Dr. Eric Bowman: We do absolutely.
Dr. Mike Patrick: So look for that past PediaCast.
Dr. Eric Bowman: Absolutely.
Dr. James MacDonald: Talk about teamwork. Again, Dr. Bowman specifically as a DO, I’ll involve him in some of my management of backpain. And then, I was going to say, I think our number one diagnosis has become concussion. That’s managed in many, many, different ways and we all see that. That again is a classic non-orthopedic problem.
But just to give a plug to Dr. Bowman, osteopathic manipulation of the neck can help a lot of the patients with concussions or headaches. It’s quite a remarkable intervention that I use Eric quite a bit with.
Dr. Eric Bowman: Yeah, it’s something that we really enjoy doing. I think it’s one of the things we love about our program, is we’re able to offer a lot of different services for a lot of individuals — not only from the manipulation to managing these conditions, but even things as we did on our last sports PediaCast, Jess with the nutritional education. I think that’s an invaluable resource. It’s so great to have her around.
Then, some of the things I know that we’re able to do as well is talk about exercise, and exercise as medicine and exercise prescriptions. I know that’s a whole other thing that we’re hoping to have, a sports PediaCast on here one of these days, but just other things like that. So, I think that’s one of the things we really like to do.
So let’s just kind of switch gears a little bit here, and we talked about the things that we’re treating and those sort of things, the scary injury happens, the pain happens, something happens. The athletic trainer says, “Hey, I think you need to go see one of the sports med docs.” What can parents and what can athletes expect or patients expect when they come in to an office setting in a sports medicine office? What are some of the general things that you may or may not see or have done?
Dr. James MacDonald: You want me to fill that first?
Dr. Eric Bowman: Yeah, sure. Either way, yeah.
Dr. James MacDonald: So first of all, you’ll probably in our clinic see someone like Gail as well as me. So, it’s another place and I think Gail had mentioned that earlier. One of the places where athletic trainers do a lot of work is in the clinic. And they’ll be, I think the best phrase is it sometimes uses a physician extender. So if I’m seeing a concussed patient, I need to get their visual acuity, how their eyes are doing and is their vision blurry. Or, normally, maybe they wear glasses and their glasses work just fine, but now, after concussion they’re not seeing right.
That kind of basic first medical evaluation, stuff like blood pressure, pulse, temperature, weight, height, visual acuity. The athletic trainer would oftentimes get the, first, history and then can be extremely useful to me as a doctor coming in, especially to alert me to some things that’s just not right. That can range from things like, “Hey, listen Jim, he’s saying his knee’s feeling fine, but there’s a large effusion,” which means a swelling. You got to pay attention to that.
Gail’s been very good at this, picking up on things like even the kind of questions we ask for teen in Nationwide Children’s, like “Do you feel safe?”Sometimes, the first entry point to identifying a child who’s at risk, it’s our athletic trainers who are picking that up and then alerting us as the doctor.
So that the parent and the child coming in to sports medicine can expect teamwork, and we’ll see that from the get-go with the athletic trainer. Somebody will call our clinic assistant and then we as doctors coming in. We tell you most of the time in our clinic, they might also expect to get an X-ray if it’s a muscular skeletal problem. And if sometimes that seems non-intuitive, once again, all I have to tell is that one condition I mentioned about the knee called Osteocondritis disecante . Somebody might legitimately say, “Hey, my son’s knees is hurting but he hasn’t had any injury in two months.” We won’t pick up a condition like that unless we get an X-ray. So very frequently, they can expect to get an X-ray.
So those are some of the basics family would expect when they come into our clinic.
Gail Swisher: I think the goal when looking for a sports medicine physician is to find the one stop shopping. So you can go in, you can be seen by the athletic trainer. You can get an X-ray if it’s appropriate. You’re seen by a physician, and then depending on what the physician thinks is appropriate for care, you can maybe get a brace or if you need a cast, or get a home exercise program. So that’s kind of a perfect world where you can do it all at once in one place.
Dr. James MacDonald: And we do work in that world. Just to extend what Gail was just saying, it even in our clinic be one-stop shopping. “OK, now, this is the physical therapy you need,” or, “This is the rehab you need with an athletic trainer.” Or, “This is the sports nutrition consult you need.” And we already alluded, “This is the osteopathic manipulation you’re going to need.” This is all that teamwork the patients and families can expect to see.
We feel blessed in our clinic, how many resources we have, and it really can be for lack of better phrase, one-stop shopping network.
Dr. Mike Patrick: It seems like a lot of folks would end up in the clinic like after they’ve had an injury. Do you see kids and recommend that they be seen preventatively? Like, I’m going to embark on a new sport, I’d like to know what kind of conditioning to prepare my body for that. Is that something that you’re open to?
Dr. James MacDonald: Yeah. It’s interesting. You’re right. Gail may want to weigh in here because at schools, that’s often done and that’s something that Gail would do with a lot of her sports teams. So be preventive about it. Let’s prevent the injuries from happening in the first place. You want to talk about that?
Gail Swisher: Our ultimate goal as an athletic trainer is to really prevent anything we can. Not all injuries are preventable, but we see things like kiddos with really tight hamstrings very frequently. That’s something, when I notice that at a practice, I can address that with our athlete and say, “Here’s how you can improve that flexibility, so maybe you can avoid a hamstring strain down the road.”
So I would say that’s a place to really utilize your athletic trainer if you’re looking for specific prevention for your child. Reach out to them first to figure out where do we need to go here.
Dr. Mike Patrick: But if you’re one of those schools that don’t have an athletic trainer, then a sports medicine clinic may be an option.
Dr. James MacDonald: Absolutely. We have formal programs that turn on that idea because you’re right, the 50% of the injuries we see are overuse. I would say by definition, at least 50% of the injuries we see are completely preventable. Overuse injuries are 100% preventable.
And so, yes, if someone’s just entering lacrosse after a winter of sitting on the couch watching the Super Bowl and what-not, and then is going to be running five miles a day in lacrosse field, that’s an accident waiting to happen.
We do have programs where people can come in. They can consult with us first and then they can get plug in to that kind of prehabilitation, so to speak — entering in the season, what do I need to do to make sure I don’t get injured? For sure, we have those.
Dr. Eric Bowman: Excellent. OK, let me just switch a little bit here. We’ve mentioned the idea of the sports med doc as being the team physician. But I guess, one of the questions people may have is the doc I see on the sideline, the doc I see covering my child’s sport, are they necessarily a sports doc? Do they have that training? Is that something’s that’s required? Is there a difference between the two? Is that something that we see?
Dr. James MacDonald: There is. It’s a really good question. For instance, in our group, like Gail and I, she has an office at Bexley High School. I show up at least on Friday nights for the football game and that’s sort of my office for like three to four hours.
There’s a several high schools in the area where you would have a sports medicine physician on the sideline. The corollary though is not true. If there’s a physician between the sideline, in many communities, that’s a good Samaritan. Could be, like maybe in Chillicothe, a high school grad, the guy who went to Chillicothe played football for Chillicothe. Now, he’s the local intern. Is there a local orthopedist? Can oftentimes provide great coverage.
But yes, you can’t necessarily say the person you see strolling the sideline is by definition a sports medicine physician.
Dr. Eric Bowman: OK.
Gail Swisher: That’s the place where I would encourage parents to seek that person out and introduce themselves and say, “Hey, what’s your background? Why did you decide to do this and get involved with the team?” Again, it’s just a matter of knowing the situation.
Dr. Eric Bowman: Absolutely. I think it’s really important to know who’s taking care of your kids. We’ve talked about, I think, before, is that you want to get to know, you want to know the people who are out there managing your child and what could be a minor injury or what could be a very scary potential neck injury. Whatever it may be, you want to know that who you have out there is… You want to know who they are. You want to know they’re helping take care of your kids. And I think that’s a great thing as well.
Dr. Mike Patrick: And it can happen. We just had the quarterback of Utah with a broken bone in the neck recently.
Dr. James MacDonald: That’s right.
Dr. Eric Bowman: Yeah, absolutely. So, all right, I think that’s great to know.
So when you work as a team physician, and we’re going to talk a little bit about that, as far as working with the athletic trainer on site and that sort of thing, what are some of the roles in the sideline as a team physician? Are you managing the whole game? Are you managing just your team? How does that usually work? What are some of your goals? What do you do on the sideline?
Dr. James MacDonald: It’s kind of like the coach sometimes may not like my calls and maybe vice versa. I’m not sure.
Dr. Eric Bowman: Exactly.
Dr. James MacDonald: No, I would tell you that I think the major person running the show on the sideline is Gail, the athletic trainer. I mean, I really look at it as I’m entering her office, and I’m there to assist. I mean that in the most sincere sense. I look at this as two pair of eyes. When someone’s coming off the field and needing tape, they’re not going to want to come to me. I mean it’s been forever since I tape them. So they’re going to seek Gail. Maybe while she’s taping that ankle, now she’s occupied. And then, it’s incumbent upon me to pay the most attention on the kickoff and what not.
And it can go vice-versa. A lot of times, the athlete trainer will be the first one running on the field when someone’s down. Maybe, let’s bring him back off the field under the sideline. It’s a knee. Gail may say, “Hey, Jim, why don’t you take a look at this knee? Can this kid keep playing? Do they need to be on crutches right now? Do we need to ship him for an X-ray right now?”
And so now, if I’m involved and examining the knee, she’s going to be turning around and focusing back on the field. So there’s definitely a give and take. But I look at it as I’m the secondary figure to the athletic trainer, to Gail, in that setting. But I also not just sting around, whistling Dixie. I’m ready to work to help her, to help the athletes.
Gail Swisher: It is a little bit of organized chaos on the sideline, so to speak, because things happen quickly but the keyword there is organized. I think the other part of it is that most of the athletic trainers are present throughout the week. So they know the athletes. They know where each one stands with his or her specific injury. Whereas, the physician probably has an understanding of that because there’s a communication there, but we’re seeing it every single day. That’s where your AT can kind of sort it through what needs to be seen by the doctor, what doesn’t, what’s the true emergency on the field, when do we need the physician on the field and that sort of thing.
Dr. James MacDonald: And invariably, the athletes, they go to Gail. They come up and feel like their finger’s hurting, they run to her. And then, she’s saying, “Hey Jim, I think he’s got a mallet finger,” “He’s a Jersey finger,” whatever. But they’re not coming to me, because again, I’m there once a week, and over the course of the season, they get to know me, and it’s really fun. It’s a really fun relationship. But I’m totally secondary to the athletic trainer who they see every day.
Dr. Eric Bowman: And I cannot echo that any more. I work with Marie at the high school. She’s the athletic trainer I work with. It’s the exact same thing. I’ve actually said what you’ve said before. It’s her show. I’m just here as the supporting cast member in a supporting role, and I’m there to do whatever we can.
I think one of the great things about the relationship on the sideline between athletic trainer and physician is the working relationship you get to form there. It’s one of those things where you ultimately start to know each other’s habits and patterns and you know what to pick up off of each other. Sometimes it may just take a look, that whole, “You need to come over here now and take a look at this one.” That’s what happened for me several times. Marie gives me the look, like “OK, you need to come look at this knee. I’m a little worried.” So I think that’s one of the great thing that’s…
Dr. James MacDonald: It’s a relationship, and it’s interesting. It can be structured in different ways. I know I’ve sometimes looked over the other sideline, and I see the physician, the athletic trainer standing together. I sort of purposely separate because again I look at it as like Gail may have one half of the field. I have the other half of the field. I want to get sort of a different perspective than she because it is organized chaos.
Actually, not to go way off on a tangent but that’s why it’s so easy — unlike NFL Sunday when you got the eye on the sky — to see that guy, “Oh my God, of course, he was concussed. How can they keep letting him play.” You’re on the sideline, your ability to see that.
Dr. Mike Patrick: You don’t have instant replay.
Dr. Eric Bowman: Yeah.
Dr. Mike Patrick: Excellent, right?
Dr. James MacDonald: Yeah, so it’s really helpful to have. I find it really helpful, like Gail is there taking a look from this direction. I’m here taking a look from this direction. But that doesn’t necessarily have to be universally the way it goes. It’s just our preference, my preference. Other doctors, athlete trainers do it differently, but it really does help to have that relationship over time.
Dr. Mike Patrick: Are you the only athletic trainer for Bexley?
Gail Swisher: No, we have another as well. His name is Aaron, so we divide things up. He covers a lot of football but I am there as well, and we sort of split things.
Dr. Mike Patrick: Yeah, because between then and basketball and volleyball and soccer, I can imagine that you get really busy fast.
Gail Swisher: Yeah, especially in the fall, we do see quite a few kids in the hour after school lets out. There are lot of games to cover because we have a lot of sports going on. It’s important that he and I work as a team as well with Dr. MacDonald to communicate, make sure everything gets taken care of and handled.
Dr. James MacDonald: The athletic trainer in the fall especially, puts many, many more hours than 40 hours a week. I’d say probably double just to start in the fall, that number. It’s crazy, the hours they work.
Dr. Eric Bowman: Absolutely. So to all of you out there, if you see your athletic trainer at your school looking a little tired about this time of the year, they’ve been working a lot.
Gail Swisher: That’s normal this time of the year.
Dr. Eric Bowman: Absolutely. For sure.
Gail Swisher: I did want to make one more note about the sideline. There is a lot of communication that goes on on a sideline when a kiddo gets hurt. The coach needs to know what’s going on, sometimes before we’ve even determined what’s the nature of the injury because they need to get that kid’s back up into the game.
So, a lot of times, after we figured out what’s going on with the injury, I’m talking to the coach about the kid status for that night and potentially beyond. And, Dr. MacDonald about, “Here’s where we’re going to go next,” “He can play tonight,” “He needs to be seen in the clinic,” “He needs to go to the emergency room.” So all that communication happens and that’s for the benefit of the athlete, of the child. To protect them and get the best possible outcome.
Dr. James MacDonald: And that’s again I’d say not a self-evident division of task, but it’s the way we work things, and I think probably the best way. I think, again, most coaches on the sideline just want one person coming in at them. For sure, in our high school, it’s Gail or Aaron. It’s the athletic trainer. I’m not the one approaching the coach and these guys in or out. It’s just like Gail and I will decide together, and then Gail or Aaron goes in.
Then, the reverse. Usually, the athletic trainer can help me identify the parent in the stands, but I’ll typically do probably most of the talking to the parents. Again, so much of it is we keep using that phrase but communication — communication between each other, communication amongst all the different stakeholders and coach, the parent, the individual themselves. So figuring those things out is really, really important. Again, that’s why having an ability to form relationships and being open and talking is huge.
Dr. Mike Patrick: So, a silly doctor question, as I’m thinking about this, as you’re having all these encounters, do you have to document that? Is there documentation for specific injuries like you would in the clinic?
Gail Swisher: Yes, absolutely. We can’t always do it while things are happening pretty quickly on the sideline, but after the fact, we do go back and write injury reports, referrals to physicians, emails, whatever follow up is needed. So that it is all clearly documented, and then we can update from there because generally, there’s going to be other things happening after the injury occurs on the day of.
Dr. James MacDonald: Again, so for high school sport specifically, that’s one of the major tasks of the athletic trainer plays, much more than the physicians — maintenance of those records, ranging from the Pre-Participation Examination to those after-injury reports. And that’s huge. So I think an organized athletic trainer with the state-of-the-art equipment, needs that computer, needs that computer interface with the hospital. It’s so important, and so we got that, where I feel fortunate.
Gail Swisher: One of the biggest thing that I’m stickler for at Bexley is if you see a physician for an injury or a major illness, you must have a note from that physician in order to return to play. The note may not say, “You may return to school today,” because school and football are completely different.
Gail Swisher: As well as the fact that you want to make sure everyone’s on the same page. So I can take that note and show it to a coach. I can show it to the parent. The athlete has seen it. Everyone knows what the note says, so it’s clear as to what the player’s status is and what care they need to be receiving at school.
Dr. Mike Patrick: I could see that being a little bit of unpopular stance with the student athlete.
Gail Swisher: Certainly when it result for them being held out from a game, which does inevitably happen several times a year.
Dr. Mike Patrick: Yeah, yeah. But it’s for their safety, their health.
Gail Swisher: It absolutely is.
Dr. Eric Bowman: I always tell people when I see them in the clinic, my role as sports medicine physician is that I want to get you back. I want you playing. That’s why I love sports medicine. It’s what I do, but I have to do it safely. I think that’s what important to understand, is that everybody on board, we really have this safety of the athlete and the child as our primary goal. We want them to play but we want them to play safe.
Dr. Mike Patrick: And that must be so difficult, because I know even just working in the urgent care, when you tell a kid, “Yeah, you have to sit out for seven to ten days, and you’re going to follow up with sports medicine,” they just give you those big brown eyes. You know what I mean? Those, “No, but it’s a tournament this weekend.” And it just tugs at your heartstrings.
Dr. Eric Bowman: And this time of the year, it gets really tough because you’re looking at the last one or two games of the season or playoffs, that sort of thing. “But, I’m a senior… ” and it’s just, you do, you get that fine line. It’s tough at times, for sure.
One last thought I just wanted to bring or just to think about — and obviously, I know that every situation can be a little bit different, and I know that if there’s a physician or an athletic trainer on the sideline, that takes priority in trumps whatever we may be discussing here — but generally speaking, are there certain things that you find out, you know what, this is something that I tend to send immediately to be evaluated for?
Is there something, certain injuries on the field, certain injuries that occur that you’re like “Well, these are things that we typically have seen right away,” versus, “Maybe this one can wait a day or two, or we can see in the clinic tomorrow,” or that sort of a thing?
Gail Swisher: I would say the big one in a game situation with football in particular but really any sports is neck pain. If the injury occurred in a certain way, which your athletic trainer should be aware of — in football, it’s head down tackling — that can be a major emergency. And that athlete needs to be taken care of appropriately on the field, with appropriate mobilization with the assistance of EMS and the physician and everyone on board to make sure that athlete get to the hospital safely and with minimum movement to their head and neck.
Dr. Eric Bowman: I know that’s always a scary thing to see, obviously. We never want to see that on the sideline. And, if you’re a parent, that’s probably one of the scariest thing you can ever see as your child on the field, being put on a spine board and sent away on an ambulance. But, I think one of the things is that it’s precautionary so often. We just had to make sure. Again, back to that safety of the kid. We really want to make sure it’s done right.
So it doesn’t matter if we think it is or if isn’t. We have to be cautious. We have to treat every neck injury in that sense as if it’s the real deal. We want to make sure these kids get appropriately taken care of.
Gail Swisher: Essentially, we look at it as if the person did have that injury until we can rule that injury out safely with an X-ray or other assessment.
Dr. James MacDonald: I’d like to joke that we’re more Clark Kent than Superman.
Dr. James MacDonald: If we had X-ray vision on the field, we might be able to real quickly, “Oh, that’s a neck. It’s going to be OK.” But you’re right. You have the right mechanism injury. They have neck pain. It’s basically an unstable neck fracture till proven otherwise. So that’s the big one I agree with Gail.
And, then, sometimes an injury happens, and a couple have happened in the high school football field this year that aren’t specific to the neck, close head injuries. There was a young man who died of splenic rupture. I those are just the ones that require…
What also, you’ll see on the side on the sideline is that someone’s pulled off. They’re injured and then, maybe they don’t go right away to the hospital. They’re not being sent away but a lot of times the physician or the athletic trainer will keep circling back and touching bases with them, re-examining, re-evaluating. And if it’s changing, the condition’s changing for the worse — sometimes, it’s not immediately apparent but 50 minutes later — now this guy needs to go, and this is why.
But those fall into sort of maybe a miscellaneous category because there are some things like dislocation in the knee or spleen injury and what-not that are just like the neck, “This has to go right now.”
And that’s the final communication piece, when you alluded to it, like emergency transport, knowing what your emergency evacuation plan is, talking to those folks and making it seamless if it has to operate. That’s huge.
Dr. Mike Patrick: I would think the athletic trainer is also going to know what local resources are available. Like obviously the neck on a back board and a neck brace is going EMS to the nearest emergency room, but, if you just needed an X-ray to rule out a fracture, it may be urgent care that sees kids or has X-ray facilities. But some urgent cares might not see kids or not have X-rays, but the athletic trainer would know like what’s available and where kids should go.
Dr. James MacDonald: And, Gail and I would be making decisions. Sometimes, on a Friday night, it gets to what Eric was saying, I’ll see hand or an ankle, and I’ll know that this is not something I think that the parent and family need to wait like four hours in emergency room on a Friday night. I know that they do not need to.
But it’s going to need to be looked at and whether it’s going in to urgent care on a Saturday morning or coming in to my clinic on Monday, we’ll… It’s called disposition, trying to figure out where and how that patient will be seen in a safe manner, but also one that’s hopefully is convenient for the family. Because no one wants to be at like three AM on a Saturday.
Dr. Mike Patrick: That’s where the art of medicine rather than the science of medicine is so important.
Dr. James MacDonald: Yeah, for sure.
Dr. Eric Bowman: Absolutely. All right, do either of you have any parting thoughts, any parting words about the sports medicine team? Anything we haven’t talked about that you wouldn’t be able to have parents and athletes out there know and that we’re aware of?
Dr. James MacDonald: Well, I just want to re-emphasize that the athletic trainers, just an integral part of that team. And I think I saw the most recent data that one-third of American high schools don’t have access to an athletic trainer, any access.
And the two-thirds figure by the way is just that some of the schools have partial access. We’re blessed with a lot of high school in Central Ohio that have full-time access. The fact that Bexley, Gail has alluded, has two athletic trainers is very unusual in the United States.
So I just want to make one last plug, if you really care about your sports safety, and I know there are financial constraints, but if we’re going to think that we can afford having sporting teams in high schools, that’s a high school that needs an athletic trainer. And almost by hook or by crook, they’ve got to get one. So that one-third that’s missing need to go down to zero.
Dr. Mike Patrick: And you don’t have to have a student athlete at home to be that advocate.
Dr. James MacDonald: No.
Dr. Mike Patrick: If you care about kids in your community and you want them to be safe, then you have a voice.
Dr. James MacDonald: You’re absolutely right. That’s right. We’re all invested in that, right, in our local school districts.
Gail Swisher: Even for coaches, that helps you be a better coach, because that’s one last thing you have to worry about when you are on the sideline. You can delegate that so to speak to your athletic trainer and let them do their thing while you coach. It also reduces liability. So there’s a lot of tremendous benefits to having an AT on staff.
Dr. James MacDonald: Yes. Insurance rates go up if you don’t have one.
Dr. James MacDonald: So it’s penny wise and pound foolish. What’s that phrase, penny wise and pound foolish, right? You’ll probably going to be paying just as much for the increased insurance premiums.
Dr. Eric Bowman: Absolutely. Like I said, I know here at Nationwide Children’s in our Sports Medicine division, our athletic trainers are a crucial part of our group. I don’t think we could function without them. In fact, I know we couldn’t function without them. They do so much for us.
My parting thought I think is just to make sure that people know that your athletic trainer is there as the advocate for your athlete and for your child. If they tell you that your child can’t play, it’s not because they don’t like your child. It’s not because they want your team to lose. It’s because they want your kid to be safe. I think that’s really important.
I just want to say thanks to Dr. MacDonald and Gail for coming out and talk about the sports medicine team. Hopefully, their Bexley team has some good success here and they do well. I just appreciate it.
Speaking of athletic trainers, I also want to just throw a quick shoutout. Thank you to Maggie Rowan and Amy Evans. They’re two of the athletic trainers in our department as well, who, for all of our Sports PediaCast, help me some of the research and topic ideas and come up with some of the content and things like that. They’re again two athletic trainers for me that are so essential to what we’re able to do here. So, I just really want to say thanks to both of them for all the help that they’ve given me on these shows and for the many more we plan to have here in the future.
I want to say thanks to everybody listening out there. I really appreciate allowing us to come back, and hopefully we’ll be back soon with sports medicine topic. So thanks again, Dr. Mike, for having us.
Dr. Mike Patrick: All right, we just have enough time to say thank you to all of you for taking time out of your day to make PediaCast a part of it. Really do appreciate that.
As always, we are just always blessed when Dr. Eric Bowman stops by the studio and co-host. These are just great sports medicine topics, very helpful. So, I really appreciate him. Also, thanks to Dr. James MacDonald — also, he’s contributed to so many PediaCast in the past — and Gail Swisher, athletic trainer here at Nationwide Children’s. Great conversation today and really was happy to have all of you able to stop by and talk about the sports medicine team.
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