OH,OH! And now what do I do?

Many times skaters are practicing without a medically trained person on hand. Although it is difficult to cover all the possible injuries or medical events that can occur in a contact sport, I will attempt to give you some general rules to help you when you have an injured or sick skater, and no medical person is on site. I have written a derby first aid manual available through me ([email protected]), the proceeds of which go to HelpTequila.com. The advice here cannot cover all possible situations and is intended to give guidance on how to proceed after an injury and not the final answer or treatment of any person’s specific injury.

This is a good time to remind leagues to have a medical review of all skaters done at the start of the season and available on site so underlying medical problems such as medicine allergies are known – especially if the skater is not fully conscious. This should include date of last tetanus booster. Remember to protect this information, it is private. A locked box with access limited to a few key people is good.

Something I recommend to have available is an automatic electronic defibrillator (AED). Although skaters are generally a young generation with little risk of heart attack, there will be skaters with heart conditions. Also, a rare but lethal event called commotio cordis (in which the heart develops an irregular rhythm) can occur from a hard blow to the heart . This is why it is important to check the heart rate or pulse for irregularity when someone receives a blow to the chest that knocks them down.

A source of ice and bags with a wrapping material (Classic wrap®, Ace-type) is invaluable since many injuries will need icing as part of the first aid treatment to relieve pain and reduce swelling.
A small first aid kit should be available with sterile gauze pads, tape, Ace-type wrap, bandaids, nasal plugs, and cleaning materials for wounds. If you are not sure about moving an injured skater, Don’t! Also, remember to keep the skater warm in cold ambient temperatures, especially if they are inactive.

If a skater goes down with a head/neck injury, you do NOT want to move them until you are absolutely sure the neck is not injured. If there is any doubt about a neck injury, the skater should NOT be moved, 911 should be called, and one person should be assigned to hold the head and neck steady until emergency personnel are there. If skater cannot wiggle the toes and fingers and/or has neck pain, do not move!

Head injuries generally should end skating for that day if there are any symptoms after 15 - 20 minutes of rest. The SCAT2 form is available (J. of Athletic Training 2009:44(4):434-448 at www.nata.org/jat) and is useful for non-medically trained people to determine if a concussion is likely. If there are symptoms of a concussion or worse, the skater should be evaluated by a doctor ASAP.

Deep, large, or rapidly swelling bruises should be iced right away, followed by a compression dressing (if the area permits) to reduce bleeding and swelling into the tissues. The compression dressing should be worn for 24 - 48 hours except for bathing. Icing should be done every 2 - 4 hours for several days to keep bleeding and swelling down. This can be done by partially unwrapping the compression and re-wrapping it over the ice.

Abrasions and cuts should be cleaned as soon as bleeding is stopped with pressure using a clean cloth or gauze. Hot soapy water is the best, but antiseptic sprays are useful if clean water is not available. Once cleaned, including any dirt or debris in the wound, a clean dressing or bandaid should cover it. If dirt or debris can’t easily be cleaned out, clean and dress the wound and see a doctor. If the wound needs sutures (if you can’t stop the bleeding or if the wound is more than a 1/2 inch long or deeper than a 1/4 inch), the skater should see a doctor within 6 hours. After 6 hours, the wound usually can’t be sutured because of the risk of infection. Be sure a tetanus booster has been given in the past 5 - 10 years. If you do need a tetanus booster, be sure that you get the version that includes whooping cough protection (i.e., Tdap). See my previous article on immunizations.

Eye injuries are often not easy to treat without medical help. If there is direct injury to the eye or a foreign body in the eye, a soft cover should be taped loosely over the eye, and the skater should seek medical help ASAP. If a chemical gets in the eye, wash the eye immediately with a minimum of a quart of clean water; identify the chemical; then go to ER.

Nasal injuries often present with bleeding. This can be stopped by having the skater sit upright with thumb and finger pressure over the front 1/3 of the nose for 10 minutes. If a nasal plug (soft gauze) is available, this can be used to stop the bleeding if pressure doesn’t. If the bleeding can’t be stopped this way, an ER visit is needed. Although nasal fractures or septum dislocations need medical treatment, this not usually an emergency, unless bleeding is uncontrolled, and the skater can see a doctor the next day.
I’ll lump bone injuries together (except for the neck as noted above).

First thing to remember, don’t move a possibly fractured part anymore than absolutely necessary. Most authorities recommend not removing gear from the injured area if at all possible. If you have to view the area (i.e.,there is bleeding), remove the gear by cutting it away while having someone hold the injured part steady. Compare with the opposite side (i.e., finger to finger, ankle to ankle, etc) - looking for deformity or swelling.

With long bones (fingers, arms, and legs), you can gently exert pressure along the long axis of the bone – if this causes bone pain, a fracture is likely. If there is major pain, rapid swelling, bruising, deformity, and inability of the skater to use or move the part without pain, assume a fracture until proven otherwise by x-ray in the ER. Splint the area with towels, scarves, blankets, shirts, cut-up cardboard boxes, wood or metal slats, or even wrapping or taping to another body part (finger to finger, arm to chest, leg to leg). Rib injuries should be evaluated in the ER if there is shortness of breath, severe pain with breathing, and persistent coughing.

Dislocations are a difficult problem. You may not know if there is a fracture as well as a dislocation, so trying to re-locate the joint can be hazardous. There are specific techniques for reducing dislocations; if you aren’t trained to do them, your best bet is to ice and splint and call for medical help ASAP.

If there is a back injury - don’t move skater right away, be sure fingers & toes work, If so - you can try moving the skater to a safer area to rest and ice. If the skater cannot move the fingers or toes or has severe pain trying to move, do not move and call for medical help.

If an abdominal or flank injury occurs, the important signs and symptoms are severe pain, vomiting, blood in urine, or fainting. If these occur, the safest course is to lay the skater down with the feet elevated and call for help. If not taken to the ER, the skater should continue to watch for these symptoms for the following 24 hours and report them ASAP to her own MD.

Genital injuries occur most often by landing on a skate. These injuries are painful but usually not dangerous. If there is no bleeding or laceration, ice and rest will usually suffice. If there is continued bleeding or a laceration, head to the ER. If there is only severe bruising, the skater should probably still see her doctor by the next day.

Nail injuries have been covered in a previous article (“Nail It Down”).

Injuries to the mouth and jaw are common in derby. With mouth guards, the injuries are usually not as serious. But lacerations of the inside of the mouth, tongue, and lips do occur. In general, if the bleeding can be stopped in 5 - 10 minutes with pressure from an ice cube wrapped in a clean cloth or gauze and if there is no tooth or gum injury, the injuries inside the mouth will heal in a few days without much treatment other than rinsing the area with hydrogen peroxide several times a day.

You will also want avoid spicy, salty, or acid foods for a few days. If tooth is knocked out, preserve it in milk, sterile saline, or inside the skater’s cheek and see a dentist ASAP. If the bleeding can’t be stopped or the gum is lacerated, go to the ER. If a cut crosses the vermillion border (red lip part) into the skin, sutures are likely needed to prevent a scar that would distort the lip. Jaw injuries that should be seen in the ER are those that cause difficulty opening or closing the mouth or have a localized painful area along the jaw bone.

The emergency situations of heat injury and dehydration have been covered in previous articles on Derbylife.com: heat injury (“No Sweat - Good or Bad”) and dehydration (“A Tall Drink of Water”).

Some general rules of thumb apply for deciding to skate or not when you are ill. If you have a fever, severe cough, shortness of breath, chest pain, uncontrolled vomiting and/or diarrhea, muscle aches, or fatigue, skating is a bad idea. If you can’t drink or eat enough to keep your hydration and strength up, don’t skate.

If you can’t skate but stay around to observe, remember to protect your fellow skaters by covering coughs and sneezes, good hand washing, and not sharing drinks, whistles, or equipment. Rashes are most likely contagious if they are crusting or blistering or have open sores - stay away from your teammates until treated. Reddened eyes with thick yellow drainage and discomfort rather than itching are likely to be contagious (i.e., pink eye) until treated for 1 - 2 days.

Allergic reactions can be very serious. If there are hives and/or itching skin with general symptoms such as breathing difficulty, problems swallowing, faintness, nausea and vomiting, you should be seeing a doctor urgently or calling 911. If there are hives without generalized symptoms, you can likely take an oral antihistamine for relief.

I wish I could address all the possible injuries and illnesses you’ll see, but I cannot in a short article. I do hope this gives you some guidance for the “Oh,Oh!” moments. If you have general medical questions (I cannot diagnose or treat individual problems without seeing the patient), please address them to me via [email protected]. Be safe, be well, and enjoy derby to the fullest.