Doctor on call
I have read with great interest the article entitled "Doc Wanted" on Friday, February 7, and the editorial in today's (Saturday's) Jamaica Observer about the absence of a doctor at practice matches of the Jamaica Cricket Association.
There are major financial implications in having medical personnel available around the clock, but having a doctor present at all times is perhaps the last piece of the puzzle.
The optimal medical coverage of any event is a matter of great debate. The International Olympic Committee has guidelines for coverage recommended for competition and practice for most sports; it categorises them from very high risk to low risk sports and advises appropriate coverage for each. The full medical team involves a sports medicine physician, a sports physiotherapist and emergency medical technicians (EMTs), with a fully equipped medical area (this may be an ambulance).
For very high risk sports, all should be present at all times in competition and practice (motor sports, for example, would fall in this category). As one goes down the categories the recommendations change from a full medical team in competition, and physiotherapist and EMT with doctor on call in practice all the way down to just having EMT present and others on call. Cricket falls on the lower end of this spectrum.
For all International Cricket Council (ICC) events it is clearly stated that the full team must be present at matches, but in practice sessions it is the prerogative of the team to arrange for coverage in advance. Of course, the assumption is that each team has a sports physiotherapist. Likewise, at all West Indies Cricket Board (WICB) international matches the same is practised. However, the structure may change at other levels with certain members of the team on call, but this is clearly stated prior to the competition.
The key issue in this matter is not whether a doctor is always present, but rather what structure is in place all the way up to emergency hospital coverage. Teams rich with resources such as most European Premier League football teams, and all professional franchise teams in North America have full medical teams on full-time employment. This is not the case with most other teams or sports.
Certainly not in County cricket sides in England, for example, or Indian Premier League teams either. But all have a sports physiotherapist. Only three international cricket teams have a full-time touring doctor (one of them has the doctor as the manager). One other may take one on certain tours.
There are inherent risks and costs in participating in sports and it is the responsibility of the organisers to minimise both. In Jamaica the overwhelming majority of events have suboptimal coverage. If a doctor is present it is usually one who is available and not necessarily one who is suitably qualified. sports medicine requires specialisation like other disciplines of medicine. Most events and teams are satisfied (or forced) to engage any doctor irrespective of their specialisation (its almost like asking a dermatologist to perform abdominal surgery or vice versa; different skill sets for different jobs).
Most teams do not have a physiotherapist though this is the norm elsewhere. Once again if they do have one, rarely is it a qualified Sports Physiotherapist. Having EMTs present with a fully equipped ambulance (defibrillators, oxygen, spinal boards, essential medications and first aid equipment and mobility for transport) is even rarer at most practice sessions and even matches. A few sporting organisations (eg, the Jamaica Football Federation) have made their presence mandatory at matches; most sports organisations cannot even afford to think about it.
It is important that the organisers of all events have structures in place that are feasible, and commit to improving them each year. This clearly highlights which members of the team are present at all times, which are on call, and where do they take injured players if further care is required. It is my recommendation that before we look at having a doctor present at all times, a sports physiotherapist is present with first aid equipment, followed by an EMT and then a sports doctor. There must be a referral hospital that is clearly identified to go to in case of emergencies. Pre-existing arrangements on who the receiving doctors are, and how payments will be made are mandatory for smooth execution. In the West Indies Cricket men's team set-up, all coaching and managing staff are certified having taken Basic Life Saving Courses.
As far as the Jamaica Cricket Association is concerned, it should be pointed out that for all national teams at all age groups, a pre-participation screen is performed routinely. Players are screened for life-threatening conditions, impending injuries or other medical conditions. This is performed by sports physicians and sports physiotherapists.
An ECG tracing is mandatory. What is lacking is the presence of a full time sports physiotherapist with teams. This is a matter debated for years but has just not been financially possible (in contrast, Barbados and Trinidad teams have routinely had one and Guyana intermittently).
Insofar as Danza Hyatt's injury is concerned, had such a person been present, a full-time doctor would not have been necessary. But under the circumstances a call was made immediately to me, and within minutes the receiving doctor at the University Hospital Accident and Emergency Unit had been informed. Following adequate assessment he was referred to the relevant specialists and ultimately had surgery performed in a timely manner.
This was not because "Dr Mansingh was called", but because of the goodwill and hard work of the rest of the team, especially the ENT surgeons who went out of their way to accommodate him outside of designated operating times.
In conclusion, I too would like that there be a doctor present at all times. But this is only after we have a full-time sports physiotherapist present with life-saving equipment at all venues, a fully equipped ambulance with EMTs present and a receiving hospital with clear chain of events planned and paid for. Till then I agree with the JCA's CEO Courtney Francis that a full-time doctor should not be a top priority.
I am etc
Dr Akshai Mansingh
Division of Sports Medicine
University of the West Indies