From the CEO Aspects of medical care for Australian athletes competing in the Indian subcontinent

By John Orchard

In September-October 2007 I travelled medical practitioner travelled with the with the Australian team to team, as intravenous fluids could have for a series of one day matches. Australia been administered during a lunch or will play away cricket matches against tea break once the diagnosis of severe the Asian teams many times the dehydration and heat stroke had been next few years. In cricket Australian established. Although Jones’ is players will also be regularly involved now part of classic Australian cricket in the (IPL) and folklore, in the fully professional era of rebel competition cricket it should be remembered that (ICL). In addition the Commonwealth intravenous rehydration is available Games will be staged in New in as a technique for qualified medical 2010. This article details some of the practitioners that significantly reduces unique medical challenges for caring for the likelihood of serious outcomes. athletes in India. As of 2008, intravenous infusions are a banned procedure under WADA History of Medical Care for rules, but are permitted “if medically Australian cricket teams on indicated” and a full Therapeutic Use 1964-65 Test scorecard, India Exemption (TUE) is submitted. These the subcontinent victorious by 2 over Australia can be approved retrospectively. Prompt According to Mike Coward1 it was Coward reported1 that the decision in emergency medical treatment should be traditional in the late 1970s and early 1984 to cease the practice of taking a administered prior to getting approval 1980s for Australian teams to travel to doctor was made for two reasons. First for a TUE. India and with accompanying it was felt (correctly) that compared to a doctors. In the past, many players were In 2007 Cricket Australia made the doctor, a physiotherapist would provide affected by serious illnesses, such as decision that both a doctor and more value for money in terms of treating hepatitis, Dengue fever and severe physiotherapist should accompany the injuries on tour, as injuries were more dehydration from gastroenteritis. The national men’s cricket team to matches common than illnesses. Secondly, by that most serious outcome from illness was in the Indian subcontinent. stage, comprehensive vaccination was on the 1959 tour of India, where four available and it was thought that illnesses players were affected by Hepatitis A. Preparation for Touring such as Hepatitis A, cholera, typhoid and One of these, Gordon Rorke, had his malaria would be very rare events due to Licence to Export first class cricket career effectively ended the modern vaccinations available. Restricted Items by the long-lasting effects of hepatitis. The most serious medical episode A printed licence to export restricted At Brabourne Stadium at CCI, involved , who was medications through customs needs to the scorecard of a famous victory for apprently not far from death from be obtained from the Commonwealth India by 2 wickets against Australia in a heat stroke during the in Department of Health & Ageing. The can Test in 1964-65 is displayed (see figure). 1986 in (Madras). Dean Jones be ordered from: [email protected] The scorecard reveals that Norman pays tribute to Errol Alcott for “saving Ph: 02 6160 3252, Fax: 02 6160 3260. O’Neill, despite selection as one of the his life” 1 in terms of providing oral Australian XI, was unable to bat in the This permit is primarily (but not rehydration and taking him to hospital game due to illness. Hence this game exclusively) for the benefit of Australian in an ambulance for intravenous was part of the tradition of Australian customs, as Indian customs (for rehydration once his momentous innings teams being severely affected by illness example) will generally treat visiting had finished. The situation may have in the subcontinent. sporting teams as they would royalty on been managed slightly differently if a arrival in the country!

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During the trip I industry in India is not the same as in took Travelan with countries like Australia, New Zealand most meals and one and England. It is probably higher for doxycycline on most those companies based in Western days for the first three countries that import to India than for weeks. [On the last local companies. My concern regarding week of the tour I the quality of Indian drugs did not was ill with an upper extend to assuming that it was likely that respiratory infection a medication may be contaminated by myself and changed a banned substance. It would be more my antibiotic to costly for a cheap Indian antibiotic to azithryomycin]. have, for example, an anabolic steroid included and therefore the likelihood Personally I was of this being the case was probably very conservative miniscule (comparable to the likelihood, with food and drink, for example, of hotel food being only drinking water contaminated with anabolic steroids). and cold drinks The concern with Indian drugs relates from bottles, even Supplementary Medical more to efficacy (for example, it is quite brushing my teeth only with bottled conceivable that the real dose of the Defence Obtained water. I generally avoided cold food drug would be lower than that stated on Medical defence organisations need and ate well- cooked (generally Indian) the packet or that the correct expiry date to grant supplementary insurance to food for most meals. I used Aerogard may not be printed). cover overseas work with a sporting (and sunscreen) whenever outside. team. Outside of the USA, this insurance This advice was given to all players Where a drug brought over from can be obtained for a nominal amount and touring staff members and it was Australia was available it obviously (approx $300). generally followed (as most were familiar was the preferred item, but a dilemma with touring the subcontinent). However, was presented when we had run out Upskilling of intravenous I doubt that players were completely of an Australian medication and it was cannulation technique fastidious about brushing teeth with the choice between an Indian one or On the presumption that intravenous bottled water and avoiding uncooked nothing. I had enough confidence in the rehydration was quite likely to be fresh food. Indian drugs available that I was willing required on the tour, I voluntarily to offer them to players. Supporting decided to revise my skills in this area. Ordering of additional this viewpoint is that fact that no Indian All Australian doctors would have medical supplies player (of which I am aware) has ever learnt this skill during their training, but Prior to the tour additional supplies tested positive for a banned substance sports physician practice does not lend needed to be ordered for my medical reported to be from inadvertent use from itself to regular practice of intravenous kit. In particular, intravenous fluid bags, an incorrectly-labelled tablet. cannulation skills. Due to this, I attended antibiotics and anti-vomiting medications My degree of confidence in Indian 5-6 operating lists and successfully plus associated equipment (e.g. giving pharmaceuticals does not extend to inserted about 25-30 IV cannulas in sets, tape) were ordered. patients who were happy to volunteer It is notable that to have me do the procedure under the pharmaceuticals are supervision of their anaesthetist. readily available in Player and Personal India and generally immunisation at prices that are 90% less than the As a first-time traveller to India I needed same products in more personal immunisation updates Australia. When than most players, who had regularly we did run out of travelled and hence were up to date supplies (notably with most immunisations. I had a blood oral antibiotics test which showed current immunity to towards the end Hepatitis A and B and Varicella-Zoster. I of the tour) it was was given injections for Adult Diptheria very easy to buy and Tetanus and typhoid, meningococcal cheap replacement and took the oral Dukoral cholera products. However, vaccine. I decided against pertussis and the quality polio updates as I had undergone the control of the regular childhood shots and a booster pharmaceutical when a medical student.

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Quinine use for prevention of cramps Quinine, a component of tonic water, has a long history as a therapeutic drug. Its major indications are prevention of both malaria and muscle cramps. As an anti-malarial, it has limited effectiveness compared to other options (particularly chloroquine the elderly. Quinine has not ever been and doxycycline). Its ‘indicated’ for prevention of sporting most common usage is cramps but only because there has never for prevention of night been adequate research for this use. cramps, which most commonly affect elderly For 14 years, I have personally Indian supplements (such as creatine, females, although it is also supervised the use of quinine by which would be relatively more likely used for the athletic cramps7 associated professional football teams in Australia to be ‘laced’ with banned agents) and with heat stress and dehydration. to prevent cramps. At the Swans, over 4 years, I would estimate that on hot days therefore I would strongly discourage Almost all of the published research 25% of the team would have taken 1 x players from using Indian supplements. on quinine involves night cramps in 300mg quinine sulphate (10% on cooler the elderly and from this it has been days). I only saw one complication, Management of concluded that quinine has mild- which was a presumed allergic reaction illness on tour moderate efficacy but with a significant to the sulphur component. At the risk of major side effects (particularly As expected, illness was very common Roosters, over 10 years, I would estimate thrombocytopenia and atrial fibrillation). in India and in fact ‘medical’ rather than that on hot days 40% of the team Because of this, the TGA (Aus) and FDA injury problems represented 37 of 93 would use one quinine tablet (15% on (US) have both removed prevention of significant player consultations on tour cooler days). I have not witnessed a cramps as a therapeutic indication of (about 40%). complication in this time. It has been quinine, although this recommendation very rare for a player to have significant The most important and significant relates particularly to night cramps in management was the use of intravenous cramps over my entire tenure as those medications and fluids in players with prolonged vomiting (+/- diarrhoea). Intravenous (“IV”) fluid use in sport is somewhat controversial but it remains a very important standard and legitimate medical treatment for dehydration outside sport. The WADA approach to intravenous fluid use is that it must be for “legitimate medical indications”. Certainly there have been past cases in sport which have crossed this line when it was previously a legal practice [particularly the Brisbane Lions in the AFL 2001-2002 prior to the practice being outlawed. In this scenario the team was routinely using IV fluids on 6-8 ‘fit’ players in each half-time break]. In the NFL it is also apparently fairly standard to use IV rehydration during matches8. I would suggest that the line in terms of acceptable use of IV rehydration (for dehydrated players) is when players are unable to orally rehydrate due to vomiting.

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players with a tendency have taken ultra-defensive medicine quinine on days in which they were (NB I would probably susceptible. take the opposite tack in an ultra litigious society Alex Kountouris (the current Australian like the USA). Acting team physiotherapist) relayed to as a “Good Samaritan” me a similar experience with the Sri for no fee is a relative Lankan cricket team, where he gave defence against approximately 5 players per match (on medicolegal action and average) a quinine tablet over 7 years. hence it is best that any This resulted in no side effects and was contract for services on extremely impressive in preventing the tour only include cramps. John Gloster, the Indian physio, athletes. reported similar experience to us and was using quinine in Indian players. Standard of I am therefore strongly of the belief, medical based on long-term anecdotal evidence, that Quinine prevents muscular cramps care in India in footballers and cricketers. Ideally an Unfortunately quality were available we were able to email and RCT would be the best way to confirm sports medicine practitioners in India have radiologists in Australia give an extra this observation. are few and far between (and hence report, which was useful. one of the justifications for taking a doctor on tour in the first place). In conclusion, the standard of sports Treating people as a medicine care in India is a lot lower “Good Samaritan” Despite plenty of income from cricket, India is still stuck in the bad old days than in Australia, but there are some It is worth reporting that I made 33 where the match day doctors can be surprising positive aspects to the Indian additional consultations with touring staff drawn from any medical specialty, no medical system. The lucrative TV rights members, match officials, members of matter how irrelevant this practice is for will require and also the media, liaison officers and even a to sports medicine (e.g. gynaecology, ensure rapid growth and improvement couple of members of the public (young paediatrics). In partial defence of the of sports medicine services in India. The cricketers) on the tour. Some of those various local cricket boards, there are majority of physiotherapists working outside our touring party approached me many cities where quality options with for cricket teams in India (especially IPL on the basis that they trusted a Western respect to sports medicine are probably and ICL) are Western (Australian, English doctor more than the Indian medical non-existent. There were some fortunate and South African in particular). It is also system. I had a personal dilemma in exceptions of orthopaedic surgeons expected that there will be excellent some of these cases as my personal with Western training/experience and high-salary opportunities for Australian medical insurance only covers “members up to date knowledge in the field of sports physicians and other sports of the touring party” and not outside sports medicine, who were a pleasure to medicine & science staff in India over parties in India. However, my own interact with. the next decade. philosophy as a doctor is that I would prefer to uphold Hippocratic principles One positive factor about the Indian References than deny giving advice out of practising medical system worth mentioning is the 1. Coward M. Cricket Beyond the Bazaar: Australia on accessibility of cheap the Indian Subcontinent: Allen & Unwin, 1990. 2. Orchard J. Intrinsic and Extrinsic Risk Factors for MRI scans. Although Muscle Strain Injury in Australian Footballers. American Journal of Sports Medicine 2001;29(3): the quality is variable, in press. the prices of scans are 3. Orchard J, Farhart P, Leopold C. Lumbar spine universally reasonable region pathology and hamstring and calf injuries in athletes: is there a connection? British Journal of by world standards. Sports Medicine 2004;38:502-4. The 1.5 Tesla scanners 4. Orchard J, Marsden J, Lord S, Garlick D. Preseason Hamstring Muscle Weakness associated with are comparable in Hamstring Muscle Injury in Australian Footballers. quality (machine American Journal of Sports Medicine 1997;25:81-85. 5. Verrall G, Slavotinek J, Barnes P. The effect of wise) to those sports specific training on reducing the incidence of found in Australia, hamstring injuries in professional Australian Rules football players. British Journal of Sports Medicine with some 0.5 Tesla 2005;39(6):363-8. scanners available 6. Orchard J. Understanding some of the risks for soft tissue inury--a Malcolm Blight legacy? Journal of and of reasonable Science and Medicine in Sport 2002;5(2):v-vii. quality for some body 7. Robertson N, Hale W, Mackler L. Does quinine reduce leg cramps for young athletes? The Journal parts. The reporting of Family Practice 2005;54(1). quality appeared to 8. Huizenga R. You’re Okay, It’s Just a Bruise. New be poor, but because York: St. Martin’s Press, 1994. electronic copies

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