In 1823, William Webb Ellis first picked up the ball in his arms and ran with it. And for the next 156 years forwards have been trying to work out why. - Tasker Watkins VC, LJ.

Friday, March 22, 2013

Concussion - New Rules, Part 2

Part One was written just after the Ireland-France match. In that game, Brian O'Driscoll and Luke Marshall both got concussed. Marshall then got concussed again in the Italy-Ireland game.

Given the track record of what happens when something is noted on this blog, I'm becoming very tempted to pay special attention to Harlequins in the first week of April, running up the game against Munster in the Stoop.

However, glib comments aside, concussion is back in the news. And a particular feature of the discussion has been people asking how O'Driscoll or Marshall were left play again.

It's that feature I want to touch on in this post, and look at the idea of contributory negligence.

There's been a fair bit on this blog about the duty of care owed by officials and coaches to players, a duty not to expose them to a foreseeable risk of harm. There's also a duty on players not to expose themselves.

This isn't about ducking out of tackles or not playing the game as hard as possible; far from it. The idea that a brain injury, which is what concussion is, is somehow not a "real" injury, or that it's somehow an indication of weakness if you have put yourself in a place where you are hit so hard your brain function is affected, is one that bedevils this area and one that needs to be removed from rugby as fast as possible. Praising a player who keeps going when clearly concussed is nonsense; the player might be an animal, but if playing concussed, then he's doing his best to turn himself into a vegetable.

Players will be injured playing the game, and that is accepted; as one case put it, anyone playing must accept their fair share of bruises, injuries and minor fractures. We all do, and it's well worth it to play the game. But players have a duty to be honest about those injuries, and not to expose themselves to the risk of further injury. If they do, then they have, of their own choice, placed themselves in a situation where they have voluntarily assumed a foreseeable risk of harm to themselves. Like driving a car without a seatbelt, they have chosen to make things more dangerous for themselves. As a result, they are at least partly to blame if they do get hurt, and must take the consequences.

This, with concussion, is where the real issue comes in. The Graduated Return to Play Protocol - the means whereby it is seen if players can safely return to the game - requires players to be symptom-free at each stage. The problem is, so many of the symptoms of concussion, for example feeling "fuzzy", or headaches, are ones that don't have external, objective symptoms; if someone chooses to keep quiet about them, they won't turn up. The same is true of baseline psychometric tests; if one choses, one can "game" the test, slowing down one's reactions so that if tested later, one can always match or beat the baseline.

The problem is, of course, that in so doing, a player who wants to play and who covers up his symptoms exposes himself to a clear risk of not just the same injury, but a worse one by being concussed again while still symptomatic. That it's foreseeable is, to be honest, now a question of stating the obvious; when it's been in the news, when the RFU announces in an injury survey released today that concussion is now the most common form of match injury in elite rugby in England and one whose incidence is not dropping, then anyone in the game is well aware that multiple concussions are a major risk.

So, then, what does this mean in practice? Well, let's return to that analogy with the seatbelt. If you are in a road-traffic accident, suffer injury because you're not wearing a seatbelt, and sue the other driver for causing you the injury, the other driver will point out that a lot, if not all, of your injury is down to your own negligence in not wearing your seatbelt. A judge hearing your case will then knock off a considerable amount of any damages you might get - 25-50% would not be uncommon - because so much of it is your fault.

In like fashion, a player who isn't honest with the team doctor, says he's asymptomatic when he's not and plays when he's still fuzzy - something O'Driscoll stated on the Off The Ball radio show that he has done - would be contributing to any subsequent injury he may suffer as a result of concussion. The IRB itself states as a basic principle in its concussion management guidelines: Players must be honest with themselves and medical staff for their protection. I stress we don't know if it happened in these cases, but an interesting comparison, in the same 13 jersey, is with Conrad Smith - a practising solicitor - who was recently suspected of concussion, left the pitch after failing a pitch-side assessment and, while frustrated, accepted entirely that it was right and necessary that this should be the case. 

The problem with concussion, of course, is that it can take years, even decades for the effects of multiple concussions, suffered when the player was hiding previous ones, to show up. By which stage, it's too late for the player.

Therefore, it's clear that there is a duty on coaches and team doctors not to put players unnecessarily in harm's way; but if they are making their assessments honestly, capably, following the GRTP and based on the information given to them by the player as to what his or her symptoms are, can it reasonably be said they have failed in that duty? And can not the finger of blame for the injuries sustained outside the framework aimed to protect players be pointed at the player who wasn't honest about his symptoms?

And all this, let us remember, when you still have the unanswerable question: if you train so hard to be able to make the right decisions, not make mistakes and not leave down your teammates, how are you helping them when you can't think straight at all?

It's time for honesty. Concussion is a brain injury, it is a risk in the game, and players need to be honest about it - with their doctors, with their teammates and with themselves.

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