A disturbing incident has emerged from the France v Fiji match on Saturday 24 November which saw Fiji claim an historic victory concerning the French No.8 Louis Picamoles. In the video below, Picamoles appears to suffer two concussive blows in little over two minutes – he is allowed to play on after the first, before suffering another. The dangers of concussion, and indeed the possible legal implications, have been discussed on this blog before (here and here respectively). With these in mind, this incident is incredibly troubling and disappointing.
The first comes in a tackle where he appears to receive a blow from behind which causes his head to strike the ground forcefully. He then stays down, on all fours, struggling to get up, before turning to lie on his back. He receives attention from the French medical team and is then allowed to play on.
When play resumes, Picamoles immediately takes contact again. France continue to carry the ball up and then, just over two minutes after receiving the first blow to the head, he receives a second. This appears to come from the boot of his teammate. This time he again remains slumped on the ground, evidently not in a good way and by the time the French doctor arrives, he appears to have almost collapsed. It is unpleasant to watch.
He then receives treatment for the second time and appears totally disorientated. His face is covered in blood and his teammate Teddy Thomas looks particularly concerned. The decision is then made to remove him from the field, at which point he struggles to walk away, before he finally leaves the field assisted.
The question coming out of this is: why on earth was he not removed from the field of play after the first blow?
Under World Rugby’s Laws of the Game (3.24):
“If, at any point during a match, a player is concussed or has suspected concussion, that player must be immediately and permanently removed from the playing area. This process is known as “Recognise and Remove”.”
World Rugby’s Head Injury Assessment (HIA) Protocol states that a player must be immediately and permanently removed from play where the following criteria (Criteria 1) are met:
“Confirmed loss of consciousness; Suspected loss of consciousness; Tonic posturing; Convulsion; Balance disturbance; Definite confusion; Not orientated in time, person, or place; Clearly dazed; Definite Behavioural changes; Oculomotor abnormalities; Other on-field identification of sign or symptoms of concussion”
If the player does not necessarily meet these criteria, they will still be required to leave the field for an HIA where they satisfy the following criteria (Criteria 2):
“Head impact event where diagnosis not immediately apparent; Possible behavioural changes; Possible confusion; Injury with the potential to result in concussion; Other concerning feature”
Whether or not Criteria 1 could be established, there is no doubt that Criteria 2 were fulfilled. There was a head impact, and the player’s body language suggested possible confusion/daze. Indeed, his behaviour would suggest that the blow had affected him and, as such, the injury had the potential to result in concussion. He should have been taken off for an HIA at the very least.
Whether the on-field medics had seen the head blow themselves or not, the watching public had seen it within seconds on the replay. A member of the French medical team in the stands should have spotted it and removed him immediately.
What happened next was incredibly dangerous: Picamoles continued to play and took another blow in a very short space of time. By this point, he was clearly exhibiting the signs of Criteria 1 and was rightly removed. But he should never have been in the position to receive the second blow.
Second Impact Syndrome (SIS) occurs when two concussions happen in a relatively short period of time, and the second concussion is inflicted before the first has fully healed. This causes the brain to lose its ability to self-regulate pressure and blood volume flowing and causes rapid and severe brain swelling.
It is an incredibly serious medical event which can result in severe disability or even death. Studies have shown that the mortality rate in confirmed SIS cases is just over 50%, while the probability of permanent disability is almost 100%.
The story of Ben Robinson serves as a reminder of just how real this danger is. In 2011, the 14-year-old schoolboy was treated three times for blows to the head before being sent back onto the field on each occasion. He then collapsed, and later died in hospital.
By failing to remove Picamoles for a HIA, the player was placed in the extreme danger of suffering SIS. It is hoped that Picamoles is doing well after Saturday’s incident and that he will make a full recovery.
“World Rugby should launch an investigation into the handling of this case”
The player has the right to feel let down by his team. While Picamoles may have been wanting to play on, and while he may not have realised what had happened to him, the doctors owe a duty of care to stop him playing on. They have the responsibility for that decision, not the player.
It was particularly odd to see Teddy Thomas’s reaction to the second incident. The winger seemed to be encouraging Picamoles to leave the field and, in truth, appeared more concerned by his teammate’s condition than the team doctor.
This is just the latest controversy involving a French team and the HIA protocol. Several times in recent memory the national side have been accused of exploiting it to their advantage, while clubs such as Clermont Auvergne and Pau have been on the receiving end of strong allegations of mistreatment in this regard.
©INPHO/James Crombie
Indeed, this author’s attention was first brought to the Picamoles incident by Cameron Pierce, the former Canadian international who was forced to retire aged 25 as a result of suffering multiple concussions. His story is told in detail here and is one example of the accusations made against French clubs for failing to look after their players.
It is not in any way alleged that Picamoles was expressly forced to play on in these circumstances. However, it is suggested that it was negligent to allow him to play on after receiving a direct impact to the head which saw him stay down like he did.
What can be done?
Firstly, it is strongly argued that World Rugby should launch an investigation into the handling of this case. Whether sanctions of any description are appropriate is a different question, but World Rugby should at least open an investigation and ensure that lessons are learned. Though the exact state of Picamoles’ current condition is unknown, the French national team can consider itself incredibly fortunate that the outcome was not far, far worse.
Secondly, it is not known whether there was an independent doctor at the match. If there was not, there should have been. World Rugby have recommended that:
“Every elite competition should have an independent match-day doctor, mandatory from 1 July, 2019 with every match-day doctor needing to complete a World Rugby match-day doctor course”
This presumably extends to autumn internationals, but why it is not immediately mandatory is unclear. There is evidently a huge need for an independent doctor. Team doctors are inevitably under team pressures – the pressures to get results. Though they will always try to be as independent as possible, they can never be entirely so by virtue of their employment. An independent doctor who reviews every incident as it happens is the only way to ensure that the HIA protocol is properly observed, and players protected.
If there was an independent doctor on Saturday, it is suggested that they got the decision wrong not to order Picamoles’ removal at the first opportunity. As World Rugby’s own slogan states, “if in doubt, sit them out”.