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 cricket team to India 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 over the dehydration and heat stroke had been next few years. In cricket Australian established. Although Jones’ innings is players will also be regularly involved now part of classic Australian cricket in the Indian Premier League (IPL) and folklore, in the fully professional era of rebel competition Indian Cricket League cricket it should be remembered that (ICL). In addition the Commonwealth intravenous rehydration is available Games will be staged in New Delhi 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 wickets 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 Pakistan 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 Mumbai CCI, involved Dean Jones, 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 Tied Test in Department of Health & Ageing. The can Test in 1964-65 is displayed (see figure). 1986 in Chennai (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! 34 Sport Health INDIAN SUbCONTINENT 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. VOLUME 26 – ISSUE 2 • WINTER 2008 35 INDIAN SUbCONTINENT 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.