Concussion in cycling: A challenge for culture & policy change

The incident below happened in the Tour of California yesterday.  Not fun footage to watch, as you may have seen.  The rider, Toms Skujins, goes down, is clearly concussed, and the first person to arrive is the cameraman followed by the race mechanic, who runs up with wheels to help Skujins continue his race (as they do, every time, per training and instruction, which I think is important, as we shall discuss).

Skujins somehow gets back on, keeps riding and is pulled from the race only later, when Jonathan Vaughters gets alerted to the issue by text messages from doctors, and manages to get to the message to team’s Director in the race.  That takes a short time, and then Skujins is pulled.

I posted some brief thoughts on this incident on Twitter earlier today, and it triggered some constructive discussion, which I thought was worth expanding on in a longer post.  So here are those thoughts, I’ll try to be brief!

La violence de cette chute… Le coureur est complètement KO debout ! (et il s'en sort très bien sur le coup) via @Christus_Rex pic.twitter.com/t5oLge3fS8

— Dans la musette (@DansLaMusette) May 16, 2017

In this instance, it’s a clear concussion, and he should never be allowed to get back on the bike, not even for 5 meters.  I think we can all agree on this.  The risk of a second head impact is one problem, but so is the risk of any accident, and we know those have potentially catastrophic consequences.

Making sure the rider is protected is thus the clear priority. But the key, which this incident highlights, is who makes the call, and how does cycling ensure that this person is able to?

Cycling’s great challenge in this regard is getting enough people who have both the expertise and authority to make this rider welfare decision to have access to the rider at the place of the incident.   It’s a question of providing enough coverage in order to “recognize and remove”.

In cycling, that’s really difficult.  Once a race has broken up, to cover the entire field with TV coverage and/or medical expertise is impossible.  In this regard, sports like rugby, ice hockey, American football are relatively easy – there’s a known location and easy access to a player with a suspected concussion.  There are 10 to 20 cameras showing the players at or near the ball, which is where any injury is likely to occur.  As a result, few incidents are missed completely, even the more subtle ones with less obvious symptoms that appear later (this is why controversies happen).

Widespread witnesses to an incident are thus not guaranteed in cycling, especially when gaps of minutes appear in a race, and there is often no footage of an incident.  This particular one happened to be caught on camera – had it been a rider even 30 seconds behind Skujins, the camera would have been 350m up the road, and there’s a chance nobody would’ve seen it.

The other problem with cycling is that if a guy goes down, then doing even the briefest of assessments to check for a head injury costs time.  It’s not like rugby where the game can stop for a short time, or where the player can leave and come back to the same match (albeit 10 min later). In cycling, if you spend even two minutes checking on the head health of a rider, that rider is up to 2km behind. Race over.

And I’m not for a second suggesting that the status of the race should trump the welfare of the rider – better safe than sorry – but the reality is that in cycling, a potential head injury is an all or nothing call, and that’s important when you’re trying to figure out a context specific solution.

It means that there’s a high risk of false positives, and while that would be acceptable if your mindset is “no compromise on rider welfare” (you’d be right), it presents a pragmatic and real-world problem for the wider acceptance of head injury, because if too many false positives occurred, it would drive the problem under the carpet as teams and riders try to hide symptoms.  These things are not simple (this is why a proposal for the straight up removal of any suspected head injury in rugby is a problem – it would actually cause more concussions to be missed or covered up).

So anyway, video footage aside, the first arriving person is the race mechanic, who has come in for some criticism for encouraging and enabling the rider to proceed, by doing his mechanical job.  I understand this criticism, but I’m also sympathetic to a couple of things.

First, that person has no mandate or authority to be on the lookout for signs and symptoms of concussion.  He has no training to recognize those signs or symptoms either, and before you call him out on the basis that this is a really obvious case (it is), just remember that he’s arriving slightly late to an incident he has not seen, is helmeted up, has cars and riders flying by him, in a frantic situation, and is probably thinking only “I need to get this guy’s bicycle up and running again”, because that’s what he is trained, paid and instructed to do.

It’s easy for us, from the sidelines, to criticize, but a little more difficult in the moment to see and then act the way we can do from our office chairs.

Second, I think the key is that the mechanic (and the cameraman, for that matter) has no authority or mandate to prevent a rider from continuing when they display clear symptoms of a head injury.  Even if that mechanic is looking at Skujins and thinking “This guy is so clearly concussed”, he has not been enabled to act on that realization.

This is really important because if you’re going to give someone the responsibility for making this decision, then you have to marry it to the authority and expertise to do so, and that has to be communicated to, and accepted by, all the participants and stakeholders in the race before the time.  This requires a policy or terms of participation agreement, because while in this instance it is obvious, think of how many will not be.

So until that combination of expertise, responsibility and authority are created, in the current culture around concussion, I think it is unreasonable to ask anyone other than a race or team doctor, or team director (as happened here, via text messages to Vaughters) to make that call, no matter how obvious it is.

What needs to change then is the general culture around concussion, allied to some policy change regarding who can “recognize and remove” injured riders.  Culture is key, and that comes from education and the gradual acceptance of what is desired in this situation.

Remember how smoking used to be sexy – camel-man, Stuyvesant etc?  It’s not anymore, and if you light up in public, you’re more likely to receive looks of condemnation than glances of admiration.  That’s because the culture has changed.

In the same way, education and awareness will change culture regarding concussion.  It is not courageous and heroic to play on, or ride on, after a head injury, and in time, that awareness will make it easier, more palatable, for people to say “Just stop, man”.

But in my opinion, that will have to be preceded by policy.  Or perhaps more accurately, culture change and policy must proceed in lock step with one another.

Drawing from rugby, I think growing awareness of the risks of head injuries helped changed the culture, and in parallel, the creation of a sideline assessment protocol, with a tool for evaluation of players and a list of criteria and actions has helped to identify and remove players with concussion far more effectively than was the case even one generation ago.

Is it perfect?  No, of course not, and the sensitivity and specificity of the tools (in rugby, this is the HIA1) must be improved, and so must the identification of what are called the Criteria 1 signs for immediate and permanent removal of players.

However, the introduction of this policy as a requirement of participation in the sport, plus education and awareness, and a lowering of the diagnostic threshold, has made it much easier to identify and respond to concussions, the result being that far fewer players who are concussed are able to continue to play.  Used to be that over half of rugby players who would later be diagnosed as concussed kept playing.  That figure is now in single digit percentages.

The same is required for cycling.  Watching the Skijuns incident, disturbing as it is, it’s actually a pretty easy one.  What would worry me more are the other crashes where a rider is also concussed, but doesn’t show such obvious signs.  Or, if the TV cameras happen to miss it, who makes the call?  The doctors and viewers never see the footage, Vaughters never sees messages, and Skujins continues to ride.

That policy is very tricky, for reasons I mentioned above – how do you blanket a fast-moving, fragmented cycling race with enough experts with authority to cover these incidents?  You can’t.

But one possibility is that race mechanics should in fact be trained and then mandated to diagnose the most obvious signs.  As I mentioned, in rugby, there are eleven so-called Criteria 1 signs that are grounds for the immediate and permanent removal of a rider.  They include confirmed or suspected loss of consciousness, convulsion, tonic posturing, balance disturbance/ataxia, confusion, being clearly dazed, being disoriented in space, time and person.

Skujins showed five, maybe six of the above eight criteria.  An easy decision, in this case, for a mechanic to make. Now, the neutral mechanic can’t perform a more complex evaluation than this, looking for oculomotor signs or a generic concussion test.  But I’d argue neither can a doctor – the race is moving on, so even if a doctor were right there, if this assessment takes five minutes (rugby’s is ten), that’s pretty decisive for the race, which is not exactly waiting.

However, in instances of clear and obvious Criteria 1 signs, as applied to cycling, I wonder if the team mechanics and other officials and support crew in the race convoy might be trained and then tasked to intervene?

There are problems with this, of course. It’s not an easy proposition.  Cost, time, training, fairness, impartiality and cheating, insurance etc all factor into it.  But given that incidents like this do happen, it seems perhaps prudent for the sport to consider creative ways to ensure that people are on site as soon as possible to recognize and remove the obvious cases, and that they have the authority to do so.

Another thing to contemplate is whether any team doctor should have the authority to make this call? You can see immediately how this becomes a slippery slope.  Doctors, you’d like to think, have a degree of separation from the competitive realities of elite sport, but it would be naive to trust only that.  It’s why teams generally make their own decisions, to remove their own rider.

But imagine a situation where nobody can see an incident except the doctor of a rival team, who is first on the scene?  That doctor should be acting to remove the rider from the race, perhaps against the rider’s wishes, and those of his team.  What happens then? Is there policy to manage such a situation?  For rider welfare, there should but, but you can see how very complex and tricky this issue is.  Perhaps more neutral, race doctors are required

I wonder too whether we are headed for a time where social media provides the footage to enable such decisions to be made.  Very little happens without some “evidence” and while you can’t allow fans to dictate medical decisions, I think there will come a time where they are providing the “data” or at least footage that allows independent neutral people to do so.

Anyway, some thoughts on a very tricky issue.

Ross

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