Welcome to the derek sheely conference, reducing catastrophic risk for student athletes. My name is brian hainline, the chief medical officer for the ncaa. I want to welcome everyone here, especially mr. And mrs. Sh eely, who will be speaking after me. Just a couple of housekeeping items. Refreshments are on the second floor. That is where we will be having lunch. This is an academic building. Classes are going on. This is being broadcast live. All of your remarks are going out to millions of people around the world who will be watching this. That is just the monday, and a few words of thanks. This is being cohosted with George Washington, University George washington university. Special thanks to president Thomas Leblanc of George Washington university, tonya vog el, the director of athletics who helped get this food together properly and chris kennelly, the associate director of athletics at George Washington university. John solomon is here from the Aspen Institute. The Aspen Institute has been doing such great work. I was involved in project play from the beginning. Theyre looking at sport as a Public Health issue. They are doing and norms important work. Enormously important work. Amy dunham helps get the good word out about sports and the way we need to keep getting the good word out about sports and keep abreast of everything that is happening. Spent countless hours to try to get this conference right. This is an academic conference. It is a conference in the living memory of derek sheely. We want to get everything about this right. This is in just a conference. This is part of is not just a conference. This is part of a movement to understand how we can mitigate catastrophic injury in sport. We have to do everything we can to mitigate the risk of sport. When i think of the ncaa and why i am so proud to be working with the ncaa, i think of john parsons, who went on to get his phd to understand how to get sport right from a Public Health point of view. Everything you do for this conference and the ncaa, and makes me proud to be working here. Y,nally, kristin and ken sheel this is the first time i got to meet you. You really have shaped this conference. You wanted to get this right in memory of derek. You wanted to get this right for the Derek Sheely Foundation. You want to get this right for how we do sport going forward. I really believe we have tried to do everything we can to get your voice into this conference because this conference really has your voice, and because it has your voice, it has the voice of derek. Prayery hope, it is my that we do get this right. Thank you for everything you have done. You have helped shape the ncaa because of your thoughtfulness and wanting to do the right thing. This is a full day. We have some incredible experts on catastrophic injury, and in the afternoon, we will have a wonderful Panel Discussion that is being hosted by the Aspen Institute and being overseen by john solomon. I think we will come away with some great information that is up to all of us to take that information and move it forward for the good of sport, for the good of society, and for the living memory of derek sheely. Thank you again. It is my honor and privilege now to introduce kristin and caken sheely. They are going to share some thoughts about derek. Ken thank you, brian, for those kind words. Welcome, everyone. I would like to welcome you to the derek sheely conference. Thank you for joining online, in haven, or on cspan as we an important dialogue on player safety. To the ncaa, Aspen Institute, George Washington university, and our speakers and moderators. This conference aims to educate you about the Risk Mitigation strategies and best practices for football. Our primary goal is to save lives through dereks story. Kristin and i would like to start the conference by sharing a few stories about derek, who you can see on screen. On april 14,n 1989, in harrisburg, pennsylvania. Earlier this week was dereks birthday. He would have turned 30, but he will is be 22 to us. He was a happy and healthy child who loved dinosaurs, cartoons, and you games. Derek was a smart and witty and kind boy. Pennsylvania, and in elementary school, derek played baseball, basketball, soccer, and for all football. When derek was eight years old, he joined the peewee football league. There were nearly 100 kids on that team, and most of the kids knew each other because they all lived in the same neighborhood. No one really knew derek because we lived outside the area because our community did not have a football team. Derek came up with a brilliant idea. Since he was a huge san fan, his plans was to wear that jersey to every practice, and he did. That little peewee team practiced six days a week, and that was not enough for derek. After rectus, he would come home and do extra situps and pushups. He had long chairs set up in the backyard so he could practice. Work was very successful. The coach and other players noticed him. He started that season on the second team. Made it say steve young to the second team. They still did not know his name, and whenever derek made a great play, the coach would say, the job, steve young. The themes of dedication, scholar, leader, champion would define dereks life. The summer before middle school, we moved to germantown, maryland. Once again, derek did not know anyone. He hadnt hit his growth spurt yet, and he was on the small side for a sixth grader. Derek boarded the bus, sat down. A few stops later, a couple of integrators got on the bus and came back to where derek was sitting. They told derek he was in his seat. In classic form, he stood u p, looked at the sea, said i dont see your names, and sat back down. The two eighthgraders beat up derek. This went on until the bus driver finally saw it happening. The two integrators were kicked off the bus for the rest of your good at that point, the other kids of the year. At that point, the other kids started thanking derek. The summer before high school, derek told us he was going to try out for the northwest football team. The announcement caught us by surprise because he had not played football since the fourth grade. He had been focusing on soccer. Uphill challenge once again because the coaches at the high school were more familiar with the other kids. That did not deter derek. His dedication, smarts, and leadership skills caught the attention of the coaches. I remember one night picking derek up, and he said the coaches told him if he kept up his efforts, he might get called up to varsity by the end of the year. That really motivated derek. He worked harder than ever in the field and the classroom. After the jv season was over, derek was one of the handful of freshmen that got called up to varsity. Northwest went on to win the state title in dereks sophomore season. As a senior, derek was elected as captain. Derek was given two awards. The award for highest fouryear gradepoint average on the team and the award for excellence in the field, classroom, and community. After high school, derek went to penn state, where he did not play football. When that first fall came around without football, derek missed it. Several of dereks High School Friends were already at or planning to transfer to Frostburg State University to play football. Kristin and i were not very excited when derek said he wanted to transfer. We made it very difficult on him. He stayed at penn state, we would pay all of his bills. If he transferred, he would have to pay his own way. Once again, that did not stop derek. He worked odd jobs and went without to pay his own way. Even though he was scraping by two pay bills, we found out later he was loaning his College Roommate and best friend money to pay the electric bills. Derek was planning a career in public service. He started the lengthy application process to join the cia. Throughout his life, derek was mature beyond his age, calm under pressure, compassion for those less fortunate, witty with a sarcastic streak that went heads, andeoples never complacent. Kristin i dont want to tell this story. I dont even want to be here today. I really dont. Am, i want to tell you the story that overshadows all the other ones we have because it is our last one. It is the story about what happened to derek. On monday, august 22, 2011, ken and i moved our daughter into her dorm room at penn state. The next morning we went out for breakfast before driving back to maryland. We talked about a lot of things, but the one topic the most were the case. We talked about dereks upcoming foruation, what to get him graduation, and i remember saying i hope he lives at home for a little while. We talked about keaton. She had been so ready for college. Her dorm was in a perfect location on campus. She and her roommates had an instant connection. How lucky keaton was. At breakfast that morning, we said how lucky we all were and that life was good. Then an hour later, we got the phone call. Son, my, my boy, my heart. My we were driving back to germantown, and i handed the phone to ken. To theped the car shoulder and slammed into a stop. We had to get to the hospital as fast as we could. That phone call left us reeling. So shaken. The injury was so severe that the doctors doubted derek would survive emergency surgery. Once at the hospital, i think i got out of the car before ken stopped. I did not know where i was going. There was a trauma nurse waiting in the lobby, and so was the narrow surgeon who told us over the phone that derek was not going to survive the surgery. The trauma was so severe that dereks brain shifted 11 millimeters from the midline. The surgery he should not have survived but did relieved the swelling, but the impact was so great that it likely would not help for the longterm. It was a shortterm solution by a small hospital to fix a catastrophic injury. That waiting room was full of coaches and trainers from frostburg. I could not look at anyone. Someone said they dont recall seeing a big hit. They dont know what happened. This morning at practice, he was fine. Then they changed for the second practice, and at some point he said he did not feel well, and he collapsed. That night, a helicopter took him to Shock Trauma Center in baltimore. One doctor asked us if derek was in a car accident. We said, no, football. The doctor asked if he was wearing a helmet. Yes, he was. Somehow we told keaton. Thatt know how we made call, book we had no choice but to ruin her life the news about her brother. Horrible weather filled that horrible week. I remember an earthquake on wednesday centered near richmond. On saturday, hurricane irene hit the east coast. I remember derek fighting for his life in the hospital for 166 hours and 52 minutes. We were told this was a freak accident. We were told there was no unusual violent hit. We were told we dont know what happened. Later, ononths thursday, march 22, 2012, we received an anonymous enough from john doe. Email from john doe. Im going to have to read the ow, titled information behind the death of derek sheely. The only changes i have made to replace the actual coaches nams with the word coach and to abbreviate the curse words. Please imagine receiving this email about someone you love. Hello, i would like to start out by saying i am very sorry for the loss of a great spirited man as derek. Known derek since the spring of 2011. Im proud to say he was a friend and teammate of mine. Ive struggled with revealing to the family some information that nto be toldforgotte to the family by the coaches or left out. I can say after reading many interviews from the family that Important Information was left out about what happened that day and the days preceding his death. The reason i have been so conflicted with telling the information with it being so vital as i did not want to cause more hurt and pain and confusion to the family after losing their son and brother. Now i feel the family must note that it was not just an ordinary concussion, but also negligence on the part of some frostburg football coaches. Playing fullback, derek was a lot of the time in the violence and grime of football. During practice, our fullbacks were working on blocking and positions, which was normal. However, the coach made it way more dangerous than it should have been. One thing fullbacks would do is run through our place so we could correct mistakes. The fullbacks were not in the current offense of position had to go and play defense. These players giving the visual could not defend themselves. When the fullback would go to block, the coach would say, knock the fh out of him. Would try to make contact to defend themselves from they were often met with fury for not following the drill. I say all of this to give background on what happened with derek. Derek happened to be one of the defenseless players just because he was caught off guard. Im not 100 sure if a helmet helmet to helmet occured, but he looked woozy. He shook it off. Later, derek told the coach he had a headache. I kind of felt like something had to be wrong because derek never showed pain. Was, stop response and bitching and moaning ord andting like a pw get back out there. Derek did as he was instructed and continued to practice for a few more minutes. Later, if only she and was called formation was called where derek was not needed. For air. Knee, gasping a few players yelled for the coaches, look at sheely. Scoffed and waited for him to get back up. When he tried, and they realized he could not, they waited a few minutes and then walked over to him and talked to him. I dont know what was said, but then they called the trainers over, and they went back to practice. That is when i went back to practice. The next thing i saw it was the trainers trying to help them off the field when suddenly he collapsed. Told tosure what was you as far as him telling the coach that he was a headache, but two coaches were aware he had a headache and took no precautions to ensure his safety. My thoughts are still with the shealy family as they have been since august 2011. That ends the email. Were it not for the courage of brandon henderson, dereks teammate and the author of the ail, we never would have known what happened to our son. We still dont know what happened. Aid fourt for medical times over three days and was told to get back on the field every time. Dereks death was preventable. Preventable. In just six days at preseason football practice, derek suffered so much brain trauma that he died. My beautiful, smart, 22yearold son in the best shape of his life. He died, and we werent there to protect him. Our lives, our family will never be the same. We will never be the same. Ken within a few weeks of in two thousand 11, we established the Derek Sheely Foundation to prevent this kind of tragedy from happening to other children. Dereks spirit is the inspiration of his foundation. Derek was recorded in a video for a school project. In the video, he said that football is the greatest sport on the face of the air. Later the earth. Later in the video, derek passionately said if you are not going to give 100 , then keep your hands off the rock. Derek loves football. We are not trying to eliminate football. We are trying to say football. Everyone knows football is a contact sport. Everyone expects coaches and trainers to put safety first and to reasonably minimize the risk. We believe football is at risk, not because of the game itself, but because of the credibility issue with footballs leaders are having with future players. We believe there are ways to reverse this trend and we have six proposals to restore the credibility of footballs leaders. Eliminate all pointless and dangerous drills from practice. Limit both the frequency and the duration of full contact practices and replace them with noncontact practices. Aid toprovide immediate all injured players and do not injuredured berate players. It seems strange to have to say this. Hold coaches, trainers, and institutions accountable for their actions and inactions. Accountability and credibility needs to come from the coaches, trainers, and institutions. They must do the right thing after they have made a mistake. Should be have erred open to being suspended, sanctioned, or banned. As far as we know, at least one of the coaches is still Coaching College football today. Investigate all catastrophic injuries and death. This is not only required to provide due process, but it is necessary to learn lessons to further improve player safety. To our knowledge, there is no investigation in dereks case. Finally, as we are here today, raise awareness. I know this seems counterintuitive, the people and institutions are more credible when they openly discussed their flaws. The commitment has to begin with real discussion be g enuine with real discussion and follow through. Finish we would like to with one of dereks favorite poems. This is the beginning of a new day. You can use this day as you will, to waste it or use it for good. What you do today is important because you are exchanging a day of your life for it. When tomorrow comes, the state will be gone forever. In its place is what you have left behind. Let it be something great. Thank you for being here to honor derek. [applause] brian thank you, mr. And mrs. Sheely. Our hope is that we do get this right. In those of you that came later, my name is brian hainline. I am the chief medical officer for the ncaa. Im going to discuss with you now a document that is going to be coming out shortly. It is an interassociation document. I will take you through the process of what that means and what it means once we actually put it out. This is just my academic disclosure. I have no conflict of interest in presenting this information. I work fulltime for the ncaa. That is my only paid work. My volunteer work is working on many Sports Medicine organizations as a member of the board of directors or medical advisory panel. Brief in this presentation, i am going to give an overview of the ncaa Sports Science institute, talk briefly about catastrophic injury in sport, describe the process of how we put together a document and review the six areas a document, and review the six areas of discussion. Let me talk briefly about the ncaa. Ncaa is thehe person speaking in front of you now. Im a fulltime paid professional on the staff. People who about 514 work in indianapolis. Our job is to serve the membership. Member schools, 500,000 student athletes, a representative democracy. Of thehe exact opposite nfl, which is more of a top down organization. We are more bottomup. Islegislation is to pass, it from 1100 member schools. World, ik around the believe we were the Second Organization in the world for a National Body or International Governing Body to have a fulltime chief medical officer. The first was fifa. They had a chief medical officer for several years. This the ncaa developed position, several other National Governing bodies have followed suit. I am a neurologist by background. Im a former football player, basketball player, baseball player, crosscountry runner, swimmer, and ultimately tennis player, and tennis is what put me through college. I still compete whenever i can. I believe very deeply in the value of sport and sport as a Public Health good. Ncaawe put together the Sports Science institute, the mission is to promote safety and wellness in student athletes. Have excellence, and achieve excellence in sport if it is in a safe environment, and if it is not in a place where the athlete is in a place of wellness. That is how we achieve excellence. We know sport is different from exercise. For all of you that are competitive athletes, and even dereks story,m if youre not giving 100 , then you dont deserve to be on the field of play. Sport is something where we often go to the edge of the cliff. We fall down. We pick ourselves back up. We fall down again. We pick ourselves back up. We challenge our spiritual, emotional, intellectual creativity in a way that we dont in exercise. Nelson mandela looked at sport, and he said he can judge a characterize an society by how that society treats sport. That is one thing we have to do in the United States of america. How does our society treat sport . Are we doing sport right . There are many ways in which we are doing sport right. We dont have a minister of sport. We are one of the few countries that dont have a minister of sport. We are one of the few countries in the world where to be a coach all you have to do is hold up a shingle and say im a coach. In our country, we specialize in despite the puberty data that tells us that is not the right way to go. Sport is a Public Health good. To get sport right, to achieve excellence, it has to be in an environment that makes sense. In the second cause of our mission, we talk about fostering lifelong physical and mental development. Physical and mental, they come together. You can never separate them. Have unequivocal data that if you have successfully repaired, perfectly biomechanically reconstructed a. C. L. , and you develop clinical depression, the chance of that acl repair being successful is significantly decreased. It will not become a functionally restored a. C. L. We have data that if you develop clinical depression or anxiety, you are at increased risk of developing musculoskeletal injury. If you have a sleep disorder, you are more likely to develop and musculoskeletal injury than if you oveovertrain. That is our mission. In our vision, it is a big bold statement. You want to be the best in the world. We say we want to be the preeminent Sports Science voice for all member institutions. We had to do something where i had to get special permission, that is to be the steward for best practices for you, intercollegiate sports. We have nothing to do with youth sport, and yet we have everything to do with youth sport. Every individual in ncaa sport works their way up through youth sport. I said, im not sure theres anything wrong with the ncaa oth er than the ncaa is part of society. That was not an adequate response. That reflected the fact that the ncaa is part of society. Is in a position more than any other governing body in ther to sport to shift landscape, to guide others to do it right. A lot of my time is spent working with youth sport organizations. It has been an amazing journey. We developed nine Strategic Priorities. The board of governors, which is the most powerful board of the ncaa, comprised of 16 president s, soon to add five independent voices. They endorsed these Strategic Priorities as priorities for the entire ncaa. All of these address sport as a Public Health matter. Cardiac health. We still have every year five to 10 student athletes who die of sudden cardiac death. Today aboutearing what we can do to mitigate that risk. Concussion, this conference is about concussion. It is about more than concussion. It is about dramatic brain injury. Traumatic brain injury. Concussion is one of the platforms that is important. Concussionn is is the right metric to be placed as a strategic priority . Is it head impact exposure . Science ishoping going to guide us to. Aning and Substance Use is important issue. Health, nutrition and sleep. Im dumbfounded by sleep, how it is the basis for so many conditions. If you develop a concussion and a sleep disorder, you will not recover from that concussion. It is the sleep disorder that will take over. Overuse injuries. With overuse comes catastrophic injuries. For every amount of overreach, you have compensatory recovery. Cannot improve in sport if you do not recover properly. Sexual assault and interpersonal violence is an issue that affects all in society. It is an unfortunate epidemic in our society. It is a big part of sport as well and ncaa student athletes. Studentprobably 20 of athletes have been victims of Sexual Violence. View, thee point of individual who is at the highest risk of Sexual Violence is the africanamerican male who is homosexual or bisexual. We need to speak about all of these issues. Datadriven decisions, these are administrative issues to get all of these issues into the right perspective. I am going to talk about a document we have been working on for the last two years. The document is reducing catastrophic injury and collegiate athletes. What is a catastrophic injury . It is defined in two ways. Traumatic catastrophic injury. Derek suffered from a traumatic catastrophic injury, which resulted in his death. Atic. Ther is nontraum these are injuries which lead to an outcome that leads to a severe injury which can be lifelong or lead to death. We have beenhen tracking carefully on this, one of the issues is investigating catastrophic injuries. We work with the National Center for catastrophic sport research. By legislation, every catastrophic injury that happens in the ncaa must be entered into al andme web port investigated independently by outside investigators and the ncaa. That is legislation that passed within the last couple of years. That was a journey in and of itself that is where we get a lot of the data behind the scenes. We have been working on understanding these injuries in high school and college athletes. There are 297 and 190 of traumatic and nontraumatic events respectively. Football has the most. One thing that has been happening is we understand now that deaths from traumatic events have been decreasing in all sports because of regulations and rule changes. Nontraumatic deaths have not been decreasing. These are also preventable. If we look at the 2017 season, there were 9 nontraumatic deaths, and 7 happened in strength and conditioning sessions. In 2003, the ncaa put forward a atization recommendation. It ended up making some sense. The National Athletic trainers out a document about mitigating suddendeath during conditioning workouts in 2012. Out sickle put cell legislation as there were a number of athletes who died who were sickle cell trait positive. I think this legislation made some sense. We are not certain that sickle cell is the right thing to be measuring. It has led to an improvement by looking at a general focus on those who are sickle cell trait positive. I told you earlier to be a coach in this country, you just have to say im a coach. That is how it also was for strength and conditioning coaches. There has been increasing movement within that profession to demand excellence in education, understanding Sports Science, being properly certified in first aid and aed. We have been trying to follow. Hrough how do we develop a document . By we i mean the ncaa. I am not now talking about the membership and Sports Science institute. There was never time in which the ncaa Sports Science institute pushes out the document says this is now what the membership must do. We always do documents in association with numerous medical and scientific organizations and with the membership. We try to make it a collective process. Let me take you through the process on this document. Two summits that just look at safety and college football. The first was 2014, and then in 2016. These summits have lead to led to some important documents. One was addressing yearround football practice contact. Mr. Sheely talked about eliminating pointless drills. Our016, when we put out yearround football practice contact recommendations, they were not perfect, but they were such that the ivy league, which had been touted as having eliminated full contact practice, they had not. Fullhad to eliminate contact practice to keep with these recommendations. Another document was a Concussion Management and diagnosis document that became a foundation for subsequent academic documents that came out. Independent medical care was addressed, which ultimately became legislation, which stated that the primary Athletics Health care providers, the Team Physicians and athletic trainers, have Autonomous Authority to make all decisionmaking. It is Holding Everyone accountable, which was another one of the action items. The accountability ultimately, medically, the responsibility is with the primary Athletics Health care providers. Legislation. Great perfectly . Ted i think were always trying to make things better. This conference that we had, we talked in 2016 about catastrophic injury. We had not addressed that in 2014. We said, how can we try to mitigate the risk of catastrophic injury . We went through this process with the document. This was overseen by a committee called the committee on competitive safeguards. At the ncaa Sports Science institute, we cannot put forward legislation. It must come through the volunteers. The committee on competitive safeguards, they are the committee we interface with for all health and safety issues, and ultimately the board of governors. Everyone had to agree we were on a path to create this document on mitigating catastrophic injury. How does this process happen . We had our son in 2016. Developed four summit in 2016. 2016. Had our summit in we put out statements that made sense. If 80 of the people said this was a valid foundational statement, then we took it to scientific and medical organizations, and if 100 of those voted for it, it became foundational statement. Then we wrote the paper. there were four primary authors. It was reviewed by the ncaa membership. That is 1100 schools. It was reviewed by the endorsing organizations. Draft, it was put forward to the committee on competitive safeguards, and they formally endorsed this document this past march 2019. They said lets move this document further through the process. These are some of the organizations that gave their endorsement to this document. People we work very closely with. The American Association of narrow logical surgeons nu eurological surgeons. Bale. Y know julian alec baldwin by in the movie concussion. I told him in person that i thought julian was much better looking, but i appreciate he at least try to step up. The American Medical Society for Sports Medicine. Several of us were at their annual meeting this past week in houston. They are Sports Medicine primary care physicians who largely represent the physicians work at ncaa schools. Same thing with the Orthopedic Society for Sports Medicine and ietyamerican osteopathic soc for Sports Medicine. D. O. s not m. D. s they are also taking care of our student athletes. The College Athletic trainer Society Working handinhand with the National Athletic trainer society. The collegiate strength and Conditioning Coaches Association. They along with the National Strength and Conditioning Association oversee strength and conditioning. Institute, whoer died of heat stroke with the minnesota vikings. They endorsed this document. E, the American Academy of neurology are about to endorse this. They gave it an affirmation of value. Why is this important . When we put out this document, this is not the ncaa saying this is the way to do things. This is 13 organizations saying we have looked at the best available data, and we believe this is the best way to put the message out about how we can mitigate or reduce catastrophic injury in sport. This shifts the dialogue so we have created a new community standard. It is a new community standard. Say this is how it is done. We do work with all of the core organizations and say help us get this right. The recommendations can be divided into six core areas. I am going to go through these core areas with you. First is sportsmanship. Mr. Sheely talked about football, he said it was a collision sport. If you read the ncaa rules about football, the first sentence aggressive,l is an rugged, contact sport. That is football. You can say the same about ice hockey. You can say the same about mens lacrosse. You can say the same about the waste field hockey the way phil hockey is often played. Way field hockey is often played. What does the second sentence say . There is no place in the sport of football to deliberately foot harm on your opponent. We must understand football is different from another contact collision sport called boxing. As a ringside doc, and as theone who was a member of new york state athletic commission, which is the official body that oversees boxing in new york, they are different sports. Cte goal of boxing is to infli traumatic brain injury on your opponent so you have one of two outcomes. Knockout, which means your brain injury is so severe that you dont have been urological capability the ne urological capability to stand up, or a technical knockout, more i believe is dangerous because you do not have the neurological disability to protect yourself. That is then when the fatal roundhouse punch can occur. Football is not meant to be contactr are any of the sports. The third sentence states that it is up to the coach to make certain that the rules of engagement are done properly. The rules of football clearly state it is a contact collision sport, but sportsmanship must be held to a different degree. But it hasnt always been held different a degree. The use of the football helmet is controversial. There were about six years in the 1930s when there were contacts discussions about whether a rigid plastic, should be introduced into the sport. There were some who said of course you must have a rigid plastic, to protect the brain. There were others who said it is going to fundamentally change the nature of the sport, and a helmet might be used as a weapon. The helmet might make people think they are invincible. But ultimately football, we have to follow sportsmanship. In this document, we talk about aggressive player sanction rules, the official rules, and the use of the helmet as a weapon. The second is protective equipment. Some of you may have seen the nfl came out with their Second Annual review of football helmets. They use a different standard. There is no one universal standard. The ncaa uses the not see standards. What is clear is a football, will not protect you against concussion. Its purpose is to mitigate against dramatic brain injury that is moderate or severe, such as a skull fracture. Important partt of our document is that we look at transition periods. A transition period is not just the fall preseason, it is after the winter break, any collectively as a team or individual when youre not in good shape, and therefore your practices must be modified accordingly. With regard to the practices, they should be consensusbased. They should be sport specific. They should never ever be we do address Emergency Action plans. If we have Emergency Action plans in place, it wont always help, but let us look at cardiac. If you have an Emergency Action plan for cardiac arrest and a defibrillator on the individual within minutes, there is a 90 chance of the individual will survive. If the individual has heatstroke and you are monitoring the court temperature, and he is in a bath,immersed icewater there is essentially a 100 chance of survival, so Emergency Action plans can and do work. This was a very controversial part of the document, and i will focus on the third bullet point that strength and conditioning personnel should not be reporting directly to sport coaches. They should be reporting to. Either the Sports Medicine or something that is evolving in parallel with the Sports Medicine , the Sports Science performing nine. This document was jointly endorsed by the collegiate strength and Conditioning Coaches Association and the National Strength and Conditioning Association. The lines of authority need to shift. Ultimately, it must come under independent medical care. The ultimate authority is the Team Physician and the athletic trainer. And finally, our sixth recommendation is how we roll out education and training to all sports coaches, to all student athletes, to all stakeholders in sports. So this document is endorsed and we are hoping for this to be implemented in august 2019. That hasnt gone through the final process yet, so i am taking a little risk by addressing this in so much detail, but i have confidence in staged really to set the and while youre here, to do this right. For derek, i am presenting this in full. This has been two years in the making. It is a start. It is not a perfect start. But it is much better than him perfect and him perfect pause. Those are my opening remarks. I would like to thank everyone for being here. We are now going to take a much more detailed look at various aspects of catastrophic injury in sports. We will start with michael emery, a cardiologist, a friend, from indiana university. He is at the institute of cardiology. Michael has actually helped us, the ncaa, and Many Organizations to put together a consensus document on cardiac screening in sport. He is someone who has really mentored us tremendously about how we need to get cardiac risk factors right. Michael, things for being here. Thanks for being here. [applause] emery sorry. I want to thank the sheely family, the foundation, and ncaa for asking me to be involved in participate. I went to speak specifically about cardiac injury in sport, cardiac arrest and cardiac deaths. I have three main objectives but i want to try to get across to everyone today. The first is to recognize incidents and ideologies of certain debts in athletes second is to describe the, curtain state and controversy of participation evaluations, and third, to understand Emergency Action plans in athletics. Alletes today come in shapes and sizes and participate in all kinds of sports. We have changed the definition of sport and athletes in the past several years. We want to see them doing what they love and excelling in their sport. See. Is not what we want to this is a picture of an attempted resuscitation of a second cardiac arrest on a pitch. This is what sudden cardiac arrest looks like an action. I will play this, there is no audio. Watch right here. Goes quickly to the ground, looks rather unimpressive, that is sudden cardiac arrest. Unfortunately, this gentleman did not survive. Sudden cardiac arrest in sports, some are very famous. Hank gathers dead, in another famous video. One player survived his sudden cardiac arrest on the pitch. This gentleman did not come he was the first picture i showed you. A step back, lets talk about death due to cardiac causes in the general population before we get into sports because that will help frame what were going to talk about. The incidence of sudden cardiac death in society increases with certain ages, and a changes in ideology. In young adolescents, it is about one in 100,000, in the general population, it tends to be from inherited cardiomyopathic processes, something they may have been born with and did not know they had. As we age, incidents of sudden cardiac death increases from acquired conditions such as coronary artery disease. Speaking of that, we often confuse these terms around and i wanted to find them before we move forward sudden cardiac arrest versus a heart attack. They are not the same. Occurscardiac arrest when the electrical system of the heart goes haywire. Think of a bowl of jello that is circulating. Llating,eart is fibri it cannot get blood to the organs. That is a sudden cardiac arrest. It is different from a heart attack, which is a sudden blockage of the arteries supplying blood to your heart. Sudden cardiac arrest is a and electrical issue. How we treat them as different. The terms are not interchangeable. We will talk about sudden cardiac arrest today. What about the death of Young Athletes . Most commonthat the cause of medical death in Young Athletes is cardiac. This was a study published about 10 years ago now from the limited data that we have, that in sudden cardiac arrest, other medical conditions are less likely, but there is a small amount of them including cell. Concussions, sickle but cardiac is the number one cause of medical death and athletes. What is that . . S it about sport is it something inherent to sport that increases someones risk . We can see from the limited studies we have that those with cardiac disease, and certain diseases with particular, as they participate in sport, their risk is higher than a nonathlete with the same condition. But it is not necessarily sport per se that causes the mortality, it is sport that triggers sudden death. In those athletes with. , these conditions that already have a cardiovascular condition, that extreme exercise potential that tips someone over the edge that may have the condition. Is the incidence of sudden cardiac death in athletes . This is not meant to look at the details but the fact that it is such a, big line, shows that we dont have a good handle on the incidence of sudden cardiac death and athletes. We do have a good handle on the numerator or the denominator. There is now mandatory. Reporting system in the u. S. Other than the ncaa, which is a small percentage. A lot of these registries are media reports insurance reports,. When we look at numbers, is it certain cardiac death so you that you didnt survive, or do we include those that had an arrest and survive . I care about those just as i care about those who passed away. Is it only those in sport . Is it on the well you are on the field that it counts . Do we add the hour after you participate . If you are an ncaa sports physician caring for the athlete in his entirety, you care about them 24 hours a day, not just on the field. If they passed away in their sleep, does it count . Depends on which registry you look at. We have numbers that range from 5000 to 100,000. It is a big range. Lots of controversy still exists, and there is a lot of questions about the incidents. We think the most acceptable 25,000. S 150,000100 went look at these numbers, how does it compare to what we know about other things . This is some of the more current data. It suggests that more than 200,000. When you look at contemporary data from the ncaa, the number seems to be higher in ncaa athletes, particularly division i males who are black. For some reason in this population, division i, male black bass of the players have in highest risk, about 1 4000. A big difference. How does it compare to what we know about other ideology. The doctor likes to compare lightning strikes to these cardiac deaths. This is Motor Vehicle deaths. Deaths due to prostate and breast cancer, deaths due to Heart Disease in 3545 euros. Izzo 3545yearolds. Here, ifcaveat far outweighs the absolute number in our ncaa division. 510 a year, but we have many more deaths than those. If your whole world revolves around taking care of ncaa athletes, that number is staggering to you. So perspective plays an Important Role here. What are common causes of sudden cardiac deaths in athletes . A fewd to group them in categories structural abnormalities, electrical abnormalities, and acquired things. We will start with structural cardiac abnormalities. Most commonly, we talk about something called hypertrophic cardiomyopathy, and inherited genetic condition that causes abnormal thickening of the heart that is unrelated to other things like blood pressure. Rithmogenic cardiomyopathy is also an inherited disorder that replaces a muscle of the heart, particularly the right side of the heart, with fact and scar tissue. Anomalies, the arteries that supply blood to the heart, that cause a heart attack, they can be born plumbing in abnormal places and abnormalities can increase the risk of sudden death. Lets focus on, and electrical cardiac abnormalities. We will focus on this one, a condition where there is an excessive pathway in the heart where the electricity can bypass the normal electrical conduction system. It is also an inherited electrical condition. And something called polymorphic particular tachycardia, where the stimulus cardiacise in his condition can lead to sudden cardiac arrest. These are pure electrical disorders on the scene on the ekg or only seen in a testing situation like a stress test. But they will not be seen by taking a picture of the heart. Than there are some acquired ideologies such as myocarditis, the information of the heart infection. Ly due to and then there is another one liocordis, the sudden impact of a small object like a baseball, a hockey talk on a compliant chest wall that will cause lenticular fibrillation and sudden cardiac arrest. The set of deaths in Young Athletes, only sort of understand some of the ideologies that cause it. Which one of the incidents are more common than the others . This is a very famous pie chart. Database, thatge is the most common disease, and it is more than a decade old, this publication. Hcm is the most common cause of sudden cardiac death in ethics. This is the same graph produced therefrom the doctor. And this is data from italy. It looks different. A 2 and if it. Cardio vascular myopathy is the more common cause. Genetic cluster in italy . Could be. Is it that way we look at the data . It could be. Is it the way that we report and register the data . It could be. The doctor uses selfreported data and uses the mandatory reporting system. This is some more contemporary data from the united kingdom, the United States military, and the ncaa. On looks very different these three graphs. Death,udden unexplained seems to be the more common cause or most common category in these three contemporary studies, meaning that based upon the scenario given, it sure sounds like cardiac. But even after it autopsy and medical review we still cant label a what exactly it was. So it is important to remember that we still cannot identify anybody for that as a sudden death, as to what their ideology was. If there are acids dying, is there a way we can mitigate this risk . This is the purpose of participation screening. The central purpose is that screening of competitive athletes to identify suspicion of those cardiovascular diseases and abnormalities that are responsible for sudden, unexpected death on the field. How do we do that . This is the american heart associations 14 element participation screaming for competitive participation screening for competitive athletes. There is a personal history section, Family History section and a physical exam,. I want you to take note of these 14 names, only four of them are physical. That tends to be the mental image of a participation screening exam. Two thirds is based on the history. You cant leave out the history. Pbe ivnt to this is the monograph, it is an organizational dust from six different organizations that have come up with a pbe. You may recognize this form, it is very well known. States require this form, they just put their own state logo on it. It has cardiac history and physical examination on it and it incorporates all of these 14 elements. That uses slightly different wording and syntax. It actually slightly improves it. But this is an important cornerstone for the standard ppe in the u. S. How good is it . It was developed by expert opinion, not by data, given by large studies. It has never been randomly studied in what we consider the gold standard, a randomized controlled trial. When we look at specificitys, we have to do it from observational studies. Observational studies are always limited. But what we have, the sensitivity of those to find disease in those who have it we think is pretty poor. The negative Likelihood Ratios are not very good. So we dont think it does in and of itself a very good job by itself. The question was brought up, can we do more advanced cardiac screening . While this is still a cornerstone, it isnt great. Should we be doing more electrocardiograms which have more heightened sensitivity to pick up more cardiac anomalies . Cardiac abnormalities . This stems from a couple of different studies. The biggest one is this study from italy that came out about 10 years ago now. The instituted a law in 1980s that mandated all athletes have an ekg as part of your evaluation. They showed an 89 in their incidents of sudden cardiac death in their effort population. Keep that number in mind. Israel did the same thing in the mid00s. When we look best in the mid1990s. When we look at their data, their number looks higher but there graph looks pretty similar. Again, italy only had a few years to collect before they had data. Israel had 12 years what the data. When we look back on their previous 12 years, they did not show a significant decrease in the incidences of cardiac death despite introducing mandatory ecg screenings. The purple line at the bottom is data from minnesota which uses the history and physical. And their incidents are about the same. The things we always have to look at was the italian sport law a measure of a rarity of the disease . Let us look at that. Those arent thousands, that is 1 par 100,000 not. 1000 per 100,000. Small numbers. Could these numbers game manipulated, or could it be a measure of their rarity of the disease . It could be. We could argue about the studies as nausea, and people have for decades, but this is to highlight the controversies that we can pick out, that maybe everythings not quite so rosy. T face value we have talked about and learned that the athletes ekg is different. We have developed these criteria over the decades, culminating in the most recent International Recommendation for electric graphic interpretation and athletes. Some of the initial data from the initial criteria suggested there was a false positive rate of upwards of 40 . 40 of athletes were told they had abnormal ecg when there was nothing wrong with thems. Then you data suggest that it is maybe 5 or 6 . Were discovered there are drastic differences with the way and athletes electrocardiogram looks compared to a normal nonathlete. There are some abnormal. Issues. These areas have to be interpreted by cardiologists who know what they are doing by interpreting these scores not, by computers. These criteria are not. In the machine you will find in a primary care physicians office. When we add the ecg, does it improve things . Do we have data that shows that it improves things . Unfortunately, we dont. Again, there have been no randomized controlled trials of these screenings, and theyre probably will not be, due to the Financial Resources it would take. It as part of the equation. But data suggest that we do dramatically increase the positive Likelihood Ratio, and improve the negative Likelihood Ratio we are more likely to find disease by utilizing an ekg. We are looking for the pathology that increases the risk of sudden cardiac death, not necessarily reducing death but just finding a pathology, equals eliminating suddendeath. That study has not been done either. But we can glean from other studies. This study was published out of an ncaa pilot study a couple of years ago, that screened 5400 athletes in 45 institutions. They found a 0. 25 of screened athletes had potentially dangerous cardiac conditions. Doesnt mean they had an abnormal ecg, it means that after further evaluations, they had a potentially dangerous cardiac condition. That would equate to about 1250 athletes in the ncaa right now who have a potentially dangerous cardiac condition. But as the doctor said earlier, only about eight deaths occur are year from it cardiac condition in the ncaa, a big gap. We still need to learn things that wending a disease think predisposes you doesnt always mean have an event. This is a recent study from the new England Development of sin that published new england journal of medicine, that published data out of the English Soccer League that mandates, physical exams, ekg and echo on every athlete. Every year the screen about 12,000 athletes. They had. 42 with potential disorders that cause cardiac conditions. Two of those went on to die, unfortunately. I want to point out that nothing is perfect. Out of the nearly 11,000 who had nothing wrong, six of them still died from a cardiac condition that was discovered in the autopsy. So they had been a screened very thoroughly and not found to have anything wrong with their screens. So we still miss people. No Screening Program will 100 find athletes who are at risk. What are some of the screening guidelines . We talked about italy and israel because it is controversial. Let us talk about. The american heart association. This is taken out. Of the European Society of cardiology and it is what they recommend an ekg in addition to history and physical is warranted on the basis of available evidence. Although the proposed screening protocol is difficult to implement in all european countries, noted, the terminology to use, they say warranted, not mandated. Says, an ekg. They dont say a whole lot than that. What does the American College of cardiology say . This is a document. Lets look at it closely. Look at the words. It says mandatory and universal mass screening is not recommended. Mandatory and universal mass screening. What does it say . It actually says that screening may be considered in relatively small cohorts, with sufficient Quality Control recognizing, the known and anticipated limitations. In our parlance, it means expert opinion. But it says, we dont recommend ,egislation at a state level, but local there is room for ekg screenings when done by people who know who they are doing, understand the risks and implications and can communicate of them to let the athletes and their family decide whether they want it done or not. The final thoughts on screaming, the criteria provided improved accuracy on falsepositive rates, but the inclusion of an ecg is as much if not more about how you handle those findings. It boils down to resources. Screening, particularly ecg inclusive is a bad practice unless you have capable screeners and readers and the resources to act quickly to resolve those findings. There is no one size that fits all. What about Emergency Action plans . We know that we cant find everyone people will elect not to have the screening. Even if we screen them, we will not find everyone. What is not controversial our Emergency Action plans. That chain of survival, calling cpr, emergency response, defibrillation, polity care. Quality when we look at sudden cardiac arrests, in 2016, the survival terrible. 12 of those who suffer an out of hospital cardiac arrest survive a discharge. Athletes. L, not just when i say discharge, i mean survive, it does not mean neurologically intact. What about athletes . As dr. Hainline mentioned, it seems to be better in athletes. Why . This twoyear data from 132 cases showed 83 survived and a certified if a certified athletic trainer was on site and involved in resuscitations. It went back. To 89 if an onsite automated external defibrillator was used. Survival needs to be better seems to be better at division i schools probably related to these resources. Period, over a 15year and this one, youre impact survival rates were 92 with an onsite aed, on the 9 without. You have to have the right equipment, you have to have the defibrillators, you have to have staff, coaches, and even other athletes ought to be trained on how to use these devices. Well communicated and well rehearsed Emergency Action plans, communication with local ems so they know how to get in and out of the stadium both on game day and during a practice, which are different. When the emergency radio cars, you are prepared, because they unfortunately. And while we dont want to see anything in the paper, i would rather see this in the newspaper, someone whose life saved because of a proper Emergency Action plan. Discussions with the ncaa. This was a peerreviewed journal document the interassociation consensus statement on cardiovascular care on student athletes, cool published in the american journal of cardiology, and the french journal of Sports Medicine. It hit all the major athletic trainers, Sports Medicine and cardiologists who would be involved in the care of athletes. Things that come out of these documents, what we talked about today identify the risk of sudden cardiac death in athletes, identifying their ideologies better, categorizing their instances better, providing the resources that you need to do these kinds of things. There is rehearsed Emergency Action plans, the cpr training. There has to be a teambased approach to the cardiovascular care of athletes. It has to involve the Sports Medicine team, the cardiologist, the athlete. They have to have a role in this as well. Everybody needs to be working in concert as a team. Thank you. [applause] thank you dr. Armory. We are going to take a 15 minute break and there are refreshments on the second floor. I will see you at 10 45