There is no sport that taught me so much about sports medicine as rugby.
In fact, I started my journey in rugby medical care the same year I started my masters in sports medicine in 2008.
The number and type of injuries I had to manage when I first started attending rugby games as a doctor were diverse enough – from impact injuries to the head and spine to bleeding wounds and musculoskeletal issues – to ensure that I rapidly improved both my medical knowledge and clinical skills.
An injured player in rugby needs to be kept safe and his injuries from being further aggravated, with the doctor delivering the required first aid on the pitch and providing further treatment off the field.
While most injuries tend to be minor, some conditions can be potentially catastrophic with long-term complications for the player.
It takes a lot to bring down a rugby player, and this can be a problem when the player just gets back up and continue playing, despite having potentially serious injuries, especially to the head and spine.
Identifying when a player has to be taken out of a game for his own health and safety, even though he may insist on continuing to play, is a crucial part of being the attending doctor at a rugby game.
Fortunately, World Rugby (WR), the global governing union for the sport, puts player welfare as a core management pillar, running various programmes in rugby medical care.
In 2013, I was recommended by my mentor to join the WR medical educator programme.
As a result, I became the first Malaysian accredited to deliver the WR First Aid in Rugby course to others, and have trained hundreds of people in this programme since 2014.
I was further accredited as a WR Medical Trainer in 2015, allowing me to teach the more advanced Immediate Care in Rugby courses and begin to train other medical educators for the rugby union.
Now, Malaysia has its own group of qualified rugby educators and care specialists.
A professional highlight
The highlight for us Asians involved in rugby was, of course, when Japan won the right to host the Rugby World Cup (RWC) this year (2019) – the first time an Asian nation has done so.
This was the best opportunity for Asian rugby medical providers to support the high performance games at the highest level tournament for this sport.
All the work that had been done in Asia in rugby care had helped us prepare for the tournament.
My own personal and professional highlight in this area was being invited to fill the role of Match Day Doctor during the RWC.
My letter of invitation was for the group match between Japan and Scotland, as well as subsequent matches, should Japan move to the next round.
I had my share of nerves as this involvement was the real deal, but this was really a once-in-a-lifetime opportunity that I wasn’t going to miss for the world.
To add to the excitement, Typhoon Hagibis, which hit the shores of Japan during the knockout stages of the tournament, posed a real threat to the tournament.
My flight had to be rearranged for safety reasons, so that I could reach Japan before the expected arrival of the storm.
The storm also significantly affected the host nation and changed the course of the RWC as a number of high profile matches had to be cancelled.
When Hagibis hit Yokohama city with its gushing wind and torrential rain, I kept myself indoors and paid attention to the TV for important updates on the typhoon’s progression.
I prayed for the safety of all the people in the affected areas and watched closely for information on the fate of the Japan-Scotland match, which was at threat of being cancelled.
The next morning was calm as the scenic Mount Fuji was visible underneath the bright clear sky; according to the locals, this is a common sight after a typhoon has hit.
It was also a big relief when I learnt that the match would go on, marking the call to work for me.
The Match Day Doctor has to be a neutral person, which is why myself and my three colleagues from Sri Lanka and Hong Kong, were invited to be part of the RWC.
As non-Japanese, we would fill this non-partisan role whenever the Japanese team had a match. The other matches all had Japanese doctors in the role of Match Day Doctor.
In general, the Match Day Doctor is responsible for enforcing all the WR laws, medical standards, guidelines, procedures, policies and protocols with regards to player injuries and medical procedures.
Most crucially, the Match Day Doctor has to rule on whether a player is injured seriously enough to be taken out of the game, usually from bleeding or concussion-related injuries.
This might result in the player being removed from the entire tournament for his own health and safety.
The highlight of my experience was the use of the Head Injury Assessment (HIA) procedure for the management of suspected concussions in the games.
The computerised CSX platform was used to record and assess head impact injury during play.
This was combined with the Hawkeye System video replay technology to support the recognition and management of head injury.
As things happen quickly during the game, it is not always clear when a player exhibits symptoms that are part of the criteria for permanent removal from the game.
These symptoms include convulsions, tonic posturing, loss (or suspected loss) of consciousness, clearly dazed appearance or ataxia (imbalance getting up on feet).
It was my first time using this procedure in the RWC and it was incredible to use technology to add precision to clinical decision-making, especially as it had to be done quickly to minimise disruption to play.
For example, in the quarterfinal match between Japan and South Africa where I also served as Match Day Doctor, two players were removed during play, following suspected head impact injuries.
One had to be permanently removed as he failed the HIA, while the other was able to return to play after he passed the assessment.
In both cases I had to ensure the management was done according to the HIA protocol.
Of course, the Match Day Doctor is just one member of the medical team for each game.
Other members of the team are the Immediate Care Lead, who leads the medical treatment for severe injuries and player extraction from the field; the Immediate Care Doctor, who treats the less severe injuries and provides care off the field; the pitchside retrieval team, who carry players off the field; the assistant Match Day Doctor, who monitors the video replay system; the Head Injury Doctor, who has to verify the diagnosis of us non-Japanese doctors as we are not licensed to practise in Japan; and the Medical Advisory Group Medical Officer, who is in charge of the entire team.
I was confident in performing my duties as I received full support from all my fellow team members.
Perfect game view
From the match perspective, I had the perfect view of the game at pitch side where I was stationed, and that experience was absolutely priceless.
The environment and the match performance were phenomenal; as it turned out, I was on duty for the most watched match between Japan and Scotland in the RWC 2019!
That match also gave me one of my most memorable moments when a moment of silence was requested for the first time in the RWC, to remember the people who died in the areas hit by Typhoon Hagibis.
It was heartwrenching to see the giant stadium screen showing the solidarity of local fans and the Japanese players, who were in tears when the Japanese national anthem was being played.
The cheers and colours of the crowd were exceptional, especially as Japan bulldozed through to beat the higher-ranking Scottish team to go down in history as the first Asian team to make it to the RWC quarterfinals.
By the final whistle of the tournament, I was completely overwhelmed; not just because it marked the completion of my duty, but also because of my pride in the contributions of so many people in protecting the safety of the players and the games.
I am truly grateful to God for this unique opportunity as I have gained invaluable learning experiences.
The importance of total preparation, effective teamwork, dynamic collaboration and trusting the process to achieve the objectives have never been more important.
I believe the values of the sport in instilling integrity, passion, solidarity, discipline and respect in people worked beautifully in the RWC 2019, and that to me, is a mark of the true success of the tournament.
Dr Azril Syazwan Mohd Ali is a consultant sports physician with the National Sports Institute. He is a member of the Asia Rugby Medical Committee and was formerly Malaysia Rugby Union Director of Medical and Player Welfare. For more information, email firstname.lastname@example.org. The information provided is for educational purposes only and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
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