Match Day Doctor Responsibilities

The Match Day Doctor (MDD) must work collaboratively with the Team Doctor (TD) to deliver the highest standard of care to players during a rugby match.

Key responsibilities are:

1. To decide which blood injuries can access 15-minute substitution – uncontrolled active bleeding.
2. Supervision of game-day management of head injuries – it is critical that the MDD works with the TD and should NOT make decisions without discussion.
3. Support the TD with on-field emergencies if requested. This may be delegated to the Immediate Care doctor if available.
4. Manage an off-field injured player if authority provided by the TD.
5. Only after collaborative discussion with the TD unilaterally remove an injured player from further game participation.

What is Uncontrolled Active Bleeding?

Players with ‘uncontrolled active bleeding can access the 15-minute blood substitution.

Uncontrolled active bleeding is:

• Bleeding that cannot be stopped within 60 seconds, or as soon as is practical.
• It is not bleeding associated with an abrasion.
• In the event that bleeding cannot be stopped with simple bandage or taping, the TD should remove the player for more advance haemostasis.
• All off-field blood injuries should be managed in the medical room or team room, and not on the sideline.

How Should The MDD Manage a Criteria 1 Sign?

1. The TD may remove the player with a Criteria 1 indicator immediately and permanently from the game.
2. If the MDD believes there is a Criteria 1 indicator the MDD should speak with the TD to facilitate removal from play.
3. If the MDD has initiated removal from play, then the video of the event should be reviewed by both the TD and MDD.
4. If both the MDD and TD agree that a Criteria 1 video sign is present, then the player is immediately and permanently removed from play.
5. If there is a dispute regarding the presence of a Criteria 1 video sign then an off-field HIA1 assessment should be performed. An abnormal off-field HIA1 assessment → permanent removal.
6. If disagreement persists after a normal off-field HIA1 assessment then a further review of the video is undertaken.
7. If, after this additional video review has been completed and disagreement persists, only then can the MDD enforce immediate and permanent removal from further play.

Importance of recognising Criteria 1 signs

1. 20% of players removed with a Criteria 1 sign will have normal HIA1, 2 & 3. This means that the presence of a Criteria 1 sign is, sometimes, the sole indicator for diagnosing the concussion.
2. Criteria 1 signs are missed regularly – a recent review of false negative cases (off-field HIA 1 assessment normal and returned to play), confirmed that 23% of these cases had a missed criteria one video sign.
3. It is possible that many of the delayed concussions we see are in fact missed or misinterpreted Criteria 1 cases.
4. Where there is doubt about Criteria 1 signs, take the time offered by the HIA1 process to re-review the injury footage, undertake the off-field HIA1 assessment and ensure that a Criteria 1 event is not present.

Off Field HIA1 Assessment & Tactical Replacement

For all players who are removed tactically, but who also are deemed to require an off-field HIA1 assessment:

• A player may only return to play (as a substitute) if the off-field HIA1 assessment is normal AND the player presents to the 4th match official within 12 minutes of starting the assessment.
• If the player has NOT returned to play (or reported to the 4th official) within 12 minutes of starting the assessment; they are considered to have had an abnormal off-field HIA1 assessment and cannot later return to play in that game.
• When an off-field HIA1 assessment is deemed normal, (even if the player has been tactically substituted), they must present themselves to the 4th official prior to the end of 12 minutes after starting the assessment. If this is not adhered to, they will be deemed to have had an abnormal HIA1 assessment, and be unable to return to the game.

HIA and all Tactical Substitutions used

• If all substitutes have been exhausted a temporary replacement for a head injury is allowed.
• If a player requires permanent removal following a head-impact event, irrespective of the criteria or the medical room classification, the temporary replacement will be permitted to remain on the field even if the player being assessed does not return after the expiry of the 12-minute off-field period.
• Tactically substituted players can return to play to replace a head injured player, even if other replacements have not been used.

Tactical vs Injury Substitutions

• If a player is removed for tactical purposes, they may return as a temporary substitute in the case of a HIA for another player.
• If the player has been removed tactically but the MDD has a suspicion of head injury (based on video or direct vision) they should discuss the case with the TD and review footage together.
• Every effort should be made to agree on whether a Criteria 1 or Criteria 2 sign is present- management of an injured player should be a collaboration.
• If no agreement is possible the MDD may insist on a HIA1 assessment and formal footage review – the MDD should make every effort to do this in a collaborative way rather than as a command.
• If a Criteria 1 sign is present the player can play no further part in the game.
• If a Criteria 2 sign is noted the player should have an off-field HIA1 assessment:
  • If the player’s off-field HIA1 assessment is normal, the 4th official must be informed inside the allocated 12 minutes. If he is not, the player will be deemed a permanent injury substitution.
  • If the 4th official is informed inside of the 12 minutes AND the off-field HIA1 assessment is normal, the player is eligible to be used as a normal substitute.

• In all cases above whether a Criteria 1 or Criteria 2 sign is seen, HIA2 must be completed at the ground and HIA3 at 36 hours

U19 Player in a HIA Approved Game

• All players 18 years and under must be managed via Recognise & Remove (R&R).
• In an HIA approved game an U19 player cannot return to play the same day following R&R even if they have access to an Advanced Level of Concussion Care.
• An U19 player who has been removed following R&R, and has access to an Advanced Level of Concussion Care, may have a concussion excluded at post-game review.
• An U19 player with a confirmed concussion must follow the individualised rehabilitation of the Home Union or World Rugby depending on who is the Tournament owner.

HIA1 Process - The role of the MDD

• In the event of a head injury to a player - ensure through video review there are no obvious Criteria 1 signs.
• Where there is an indication for an off-field HIA1 assessment, it should have been agreed in advance who would perform this assessment. If the TD completes the assessment the MDD should observe the process.
• Research has shown that when doctors perform the off-field HIA 1 assessment, those who use clinical judgement are more accurate than when either baseline data or normative data alone is used – a clinical approach is helpful.
• The SCRM system has submode baselines uploaded for each player. If SCRM is not available or you do not have baseline data - normative ranges are proposed within the HIA paper documents. These normative ranges should only be used when individual baseline is not available.

Recent changes to the HIA1 Assessment

Off-field HIA1 assessment

• 10-word Immediate Memory and Delayed Recall list have replaced the 5-word tests.
• The tandem gait has been replaced by the mBESS – single leg stance and tandem stance.
• Sub-threshold Criteria 1 signs are now indicators for an off-field HIA1 assessment.
• The symptoms checklist must be handed to the player for reading aloud.

HIA1 Process

• The orientation questions, 10-word lists, digits backwards and instructions for mBESS testing are now available in audio files within the SCRM App. These audio files may be used to instruct the player.
• Where the MDD speaks a different language to the player being tested, the player may be tested in their language via the embedded audio files in SCRM . An interpreter may be used to check correct answers.
• The best results in the HIA process are achieved when the approach is collaborative rather than combative. The MDD and TD should work as a team to ensure the best player care is provided.