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S.E.R.I.O.U.S. method for dealing with Injuries.

INTRODUCTION:

The Powers and Duties of the Referee listed in Law 5, state that the Referee is responsible, and has a duty to stop the match if, in his opinion, a player is seriously injured and ensures that he is removed from the field of play. An injured player may only return to the field of play after the match has restarted.

The Referee can also allow play to continue until the ball is out of play if a player is, in his opinion, only slightly injured. It is his duty to ensure that any player bleeding from a wound leaves the field of play. The player may only return on receiving a signal from the Referee, who must be satisfied that the bleeding has stopped.

One development area surprisingly deficient in many football/soccer Referees' capabilities, is a standard process for dealing with injury situations on the field of play. Invariably, the Referee (in good faith) deals with each situation with the health and safety of the injured player paramount. But very often, there is little (or no) thought given, to proactively preventing eager trainers from rushing onto the field of play. Sensible positioning by the Referee (whilst inspecting the injury) is also sometimes missing. The Referee has a duty to monitor all of the players, and not just the one who is injured. Another worrying aspect is the amount of times that the Referee wanders away from the injury location, to have friendly conversation with the other players whilst the injury is being dealt with. Without a set process to consider, it is also not surprising, that on some occasions, the Referee forgets to ask the treated player to leave the field of play, and to await a signal to re-enter at a suitable time after play has been restarted. The advice shown here, encourages Referees to use a set process for managing injuries. Whilst the advice may differ from that used in other countries, it is not meant as a definitive guide, but as a basis for improving the process used when dealing with injury situations. Also included, is a selection of relevant information included in official publications.

Making contact with the trainers/medical staff before the game starts:

Prior to kick-off, the Referee (and Assistant Referees) should try and make contact with the team trainers (or medical staff) and remind them to await the Referee's signal before entering the field of play when an injury occurs. The Referee should demonstrate the outstretched beckoning arm/palm signal that he will be using to summon the trainers/medical staff onto the field of play to assess an injury. The trainers/medical staff should be reminded that if it is possible to safely remove an injured player, treatment should not be applied on the field of play. But that the players' health and safety must always be paramount.

The S.ER.I.O.U.S. (a standard process for dealing with injuries in the field of play.)

Serious?(The first consideration is to decide if an injury is serious or not.)
Evaluate? (Evaluate each injury situation as it arises. Does play need to be stopped?)
Race. (Sprinting to the scene of the injury).
Inspect. (Taking up a position that allows inspection of the injury and monitoring the remaining players).

Organise. (Taking charge, positioning and seeking medical assistance if it is required).
Usher. (Overseeing the safe removal of injured players).
Start. (Starting the game again after the injury has been seen to).

Serious? (The first consideration is to decide if an injury is serious or not.)

When an injury situation occurs, the first consideration for the Referee - is to decide if the injury is serious or not.
As soon as the Referee has authorised the trainer/medical staff to enter the field, the injured player must leave the field, whether he receives treatment or not. If the player does nor comply, he should be cautioned.
Exceptions to this ruling are made only for:

o (i) an injury to a goalkeeper;

o (ii) when a goalkeeper and an outfield player have collided and need immediate attention;

o (iii) when a severe injury has occurred e.g. swallowed tongue, concussion, broken leg etc.

The Referee should note the position of the ball if the game has to be stopped, so that the correct restart can be applied once the injury has been dealt with. It is very easy to forget the type of restart, or the location of the restart when focusing on the injury. In the pre-match brief to the Assistant Referees, the Referee should instruct the Assistants to make a note of the required restart. This will aid the Referee if he forgets!
If there is any discipline action to be taken as a result of the injury, the Referee should firstly organise any treatment for the injured player, before taking any discipline action.
There may be occasions when the Referee will need to fend off angry players crowding around the injury scene. This must be done assertively and in conjunction with help from the Assistant Referees if required. The Assistant Referees must be briefed as to their role in such circumstances.
If the delay for dealing with the injury, is likely to be long, the Referee can stop his watch.
Referees are instructed to add the full amount of time lost for injury delays at the end of each period of play.

If the injury is serious:

For example, if the injury is to the head or neck or is a serious bleeding injury, broken bones, concussion, torn ligaments, or involves breathing difficulties, the Referee should stop play and summon the trainer/medical staff immediately.

Referees should certainly always stop play immediately and summon medical aid if a serious head injury is suspected.
The Referee should try and recognise serious injuries by looking out for body signs such as an inert unconscious body, or obvious pain, or genuine concern expressed by other players near the scene. If there is any doubt as to the seriousness of an injury, (especially if a young child is involved), the Referee must always err on the side of caution by summoning medical aid immediately.
A player's health is far more important than a game of football/soccer.
Summoning the trainer/medical staff, can be done immediately by using a loud whistle, vocal instructions and by waving a beckoning arm/palm towards the Technical Area, or towards the vicinity of where the team�s trainer/medical staff is located.
If there are players injured from both teams, then waving two beckoning arms will clearly show that both of the competing team�s trainers are urgently required.
Assistant Referees should also play their part in summoning on trainers/medical staff in cases of urgency.
In local Park level football, when there are no medically qualified personnel in attendance, professional assistance should be quickly obtained for serious injuries, and the advice offered, acted upon.

What is serious injury?

A serious injury cannot be easily defined in just a few words; but should be fairly obvious to spot.
A serious injury can have a major impact upon the life of the player and warrant possible compensation if caused by wilful misconduct or negligent treatment or movement of the player.
Referees must be particularly vigilant when young players are concerned � a serious injury can have a significant impact on the development of a child.
Another factor in considering the seriousness of an injury is the impact on the victim's earnings and lifestyle. An injury that causes a substantial loss of earnings or earning capacity would be termed "serious". Also, an injury that requires a player to make major accommodations to their lifestyle is also serious.
Serious injury is when there is harm done to the body that causes severe, permanent or protracted loss of or impairment to the health or to the function of any part of the body.
Serious injury can have devastating consequences for the player and their family.
Serious injury affects the whole person, from physical abilities to changes in the quality of life.
The Referee should never sanction the movement of a player who has possible internal injuries without seeking the authority of the trainer/medical staff.

Some examples of serious injury that can occur to a player in a game of football/soccer are:

becomes unconscious.
has trouble breathing or is breathing in a strange way.
has swallowed his tongue
has chest pain or pressure.
is bleeding severely.
has pressure or pain in the abdomen that does not go away.
is vomiting or passing blood.
has seizures, a severe headache, or slurred speech or blurred vision.
has injuries to the head, neck, or back.
has possible broken bones.
disfigurement (significant scarring or burns)
spinal cord injuries
heart attack

Why is a head injury so serious?

A head injury may cause serious injury to the brain, even when there is no visible bleeding or injury visible on the outside of the skull.
The impact of a hard blow to the head may jar or shake the brain within the skull (closed head injury).
The rapid movement of the brain within the skull can cause bruising, swelling, or tearing of the brain tissue. It can also stretch, pull apart, or tear nerves or blood vessels within or around the brain.
Head injuries can sometimes be more complex when players have been taking alcohol or drugs, which can make injury evaluation and recognition difficult. Do not assume any altered behaviour is only from alcohol or drug use.
Where serious head, neck or back injuries are suspected, any movement by untrained hands has the greatest consequences. The player should be immobilized pending arrival of medical personnel.

A serious head injury may include some of the following symptoms:

A severe headache or a headache that continues to get worse.
Confusion or abnormal behaviour.
A young player with a head injury may be extremely irritable or fretful or may cry constantly.
Difficulty with staying awake.
Slurred speech.
Numbness, weakness, or loss of movement in the arms or legs.
Vision changes and changes in the pupils' size, shape, and reaction to light.
Dizziness, nausea, vertigo, or unsteadiness that prevents standing or walking.
Bleeding from the ears or elsewhere on the head.
May have unequal pupils
Altered level of consciousness

Immediately after a head injury occurs, it can be difficult to tell the difference between a mild concussion and a more serious injury. A brain bruise (contusion) or bleeding within the skull at first may cause only mild symptoms.

Players who have experienced a head injury should be watched carefully for 24 hours.

If serious head injury is suspected, an immediate visit to the hospital or to a Doctor is essential. Players who have suffered from concussion should be advised not to play any further part in the game.

What is concussion?

CONCUSSION is an internal head injury. Of all the head injuries, this is the most insidious, and many casualties have succumbed several hours after the incident.

The Referee should be especially observant when contact involves children - the myth that you can 'run off' concussion by 'playing on', is a dangerous attitude, and has caused grief and embarrassment to many players, parents and coaches when the player eventually collapses.

Concussion is potentially very serious, and an indifferent attitude is to be discouraged.

What are the signs and symptoms of fractured bones?

Some, or all, of the following:

� pale, cool, clammy skin

� rapid, weak pulse

� pain at the site

� tenderness

� loss of power to limb

� associated wound and blood loss

� associated organ damage

� nausea

� deformity

� crepitus

Are damaged ligaments more serious than a broken bone?

Bones are connected to each other in joints by ligaments. When excessive force is applied to joint, ligaments may be torn or damaged. This type of injury is a sprain.

The seriousness of a sprain depends on how badly ligaments are damaged. Sprains can occur in any joint, but they occur most commonly in the ankle, knee, and finger.

Damaged ligaments can be more serious than a broken bone.
Great care must be taken to isolate the injury.
Moving unsupported and properly bandaged injuries can have a devastating effect in causing further injury and pain to the injured player.
Where serious neck or back injuries are suspected, any movement by untrained hands has the greatest consequences. The player should be immobilized pending arrival of medical personnel.

Should the Referee allow a dirty sponge or dirty bucket of water to be used?

Precautions for reducing the potential for transmission of infectious diseases must be considered.
Whilst the Referee is not responsible for administering treatment, he should advise against dirty (or previously used) water from a bucket being used to treat an injury - particularly if the injury is an open wound.
Dirty water is a carrier of disease, and players can become contaminated as a result of negligent treatment.
The soccer community is like all other segments of society. Some participants may have infectious diseases including HIV/AIDS and Hepatitis B (blood borne pathogens). Treat every person on the field, as in any area of society, with the assumption they could be HIV positive.
Contaminated towels, dressings, and other articles containing body fluids should be properly disposed of or disinfected.

Evaluate? (Evaluate each injury situation as it arises. Does play need to be stopped?)

The Referee will need to quickly evaluate each injury situation as it arises. Initial evaluation can sometimes be done from a distance, but on other occasions, the Referee will need to evaluate the seriousness of an injury from close quarters. Whether to stop play or not, depends on a number of factors which will need to be taken into consideration. Some of these are listed below:

The first consideration as mentioned above, is for the Referee to evaluate whether the injury is serious or not, and to subsequently decide if play should be stopped or not.
Is the injured player in the way of ensuing play, which constitutes a further danger to himself or to other players; or is he in a safe location that does not involve the development of the current phase of play?
Is the injury to a goalkeeper?
Is blood leakage involved?
Does it look like one of the teams are about to kick the ball out of play to allow the injury to be dealt with?
In general terms for non-serious injuries, the Referee should encourage play to continue. The decision for stopping play or not, is for the Referee to make in accordance with Law 5.
If a team purposefully kicks the ball out to allow treatment, then the Referee should be sympathetic to the gesture. Nevertheless, problems have occurred, when following the restart, the ball is not returned to the team who kicked it out of play. The Referee must therefore be vigilant and deal with the restart assertively, to ensure that the players do not abuse �The Spirit of this Gesture�.
Does the injury involve a young child?
Is the injury being simulated?
Is the injury likely to result in retaliation?
Does it look like the player may make a quick recovery?
Has the player lain himself down on the ground, thereby indicating that he requires treatment?
Has the manager instructed the player to drop to the ground?
Is there an element of time wasting involved? There are occasions when the Referee stops a game in order that an injured player might be attended to, and the player will not be as seriously injured as first thought. In fact, at the first squirt of magic water, the player is ready to play on. If players are wasting time, the Referee will need to deal with this in accordance with the Laws.
Is the tempo of the game such, that a forced stoppage by the Referee will provide an opportunity that allows tempers to cool?
Does the injury occur just as a goal scoring opportunity is developing?
Does the injury involve the need for disciplinary action to be taken?
Can the injured player make his own way off the field to receive treatment? (Including being near enough to the touchline/goal line to roll himself off).
Will the weather have an adverse effect, if treatment is delayed?
Does the injury involve a vulnerable player? For example, someone who suffers from asthma or is recovering from a previous injury.

If the player is only slightly injured.

If the player is only slightly injured (for example, a thigh strain or cramp), the Referee will need to decide if play can be allowed to continue until a natural stoppage.
The Referee should allow play to continue until the ball naturally goes out of play if a player is, in his opinion, only slightly injured.
On some occasions, the ball may be purposefully kicked out of play by a sympathetic player, thus allowing the Referee to temporarily suspend the game to allow the injury situation to be dealt with.
If an injured player is able to safely leave the field of play without help, then he should be encouraged to do so.
If the player is bleeding slightly, the Referee can instruct the player to leave the field of play. The player may only return when authorised by the Referee who must check that bleeding has stopped and is suitably covered. The Fourth Official or an Assistant Referee may assist the Referee in checking the player, before they return to the field of play.
A player cannot wear clothing with blood on it, or clothing that has been contaminated with blood.
Players uniforms contaminated with blood should be changed. They should NOT be rinsed out and re-worn. Referees should never allow the player back onto the field without a clean jersey, shorts, shoes, etc., whatever has had the blood on it.

Race. (Sprinting to the scene of the injury).

When a natural stoppage in play occurs (or if play has been subsequently stopped for a serious injury) the Referee should RACE towards the injured player.
A Referee who ambles towards an injury location, emits a signal that says, "I don't care for the well-being" of the players under my charge today", whereas a Referee who RACES towards the scene, shows that he is genuinely concerned, and eager to seek medical help if required.
Prior to summoning on the trainers/medical staff, the Referee needs to make an initial assessment before he can get to the scene. Does the injured player immediately require the trainer/medical staff assistance?
If the Referee is some distance away from the scene, he should look out for the body language of any players near the scene. Any signs of distress from them should be used as a trigger to seeking help immediately.
For non-serious injuries, whilst RACING towards the injured player, the Referee should use an outstretched palm to delay the entry of any over-eager trainers/medical staff. This is important, for as soon as the Referee has authorised the trainers/medical staff to enter the field, the player must leave the field whether he has received treatment on the field or not. In other words, the player should at least be evaluated by the Referee, and given the option by the Referee to request help from the trainer/medical staff if required.
When young children are involved, parents very often rush onto the field of play when their child gets injured. The Referee must be sympathetic to the parent's concerns, and manage each circumstance carefully (without antagonising the situation). In these situations, it's more a case of educating the parents, rather than strictly adhering to the duties and responsibilities as laid out in the Laws.

Inspect. (Taking up a position that allows inspection of the injury and monitoring the remaining players).

Inspecting and assessing the injury:

On arrival at the injury scene, and after correctly positioning himself, the Referee should ask the injured player if he requires a trainer/medical staff; using words to the effect of, "Do you want your trainer".
The Referee should not say, "Do you require treatment?" Otherwise the player will assume that the Referee will allow treatment on the field of play.
If on arrival at the scene, it is apparent that the player is in obvious need of prompt medical assistance, the Referee should summon aid immediately (there is no need to ask a severely distressed player if he needs treatment).
After questioning the injured player, the Referee authorises one, or at most two trainers/medical staff, to enter the field to ascertain the type of injury and to arrange the player�s safe and swift removal from the field by the shortest route or by stretcher or by walking.
Important Note: It is imperative, that the Referee does not make the decision to remove a player with a serious injury from the field of play, or to make a decision to call for a stretcher to be provided. The Referee must first seek this advice and authority for removal from the trainer/medical staff. He can do this by engaging with the trainer/medical staff by asking them if it is possible to remove the player without incurring further injury or distress. Once this has been achieved, the Referee can summon a stretcher. If a Referee calls for the stretcher, or insists that a player be removed without recourse to the trainer/medical staff, it could have dire consequences for the Referee, if the injury involves damage to the spine, head or is a serious fracture (and the hasty removal on the Referee's sole authority causes further trauma to the injured player).
The bottom line is, that when a serious injury is suspected, the Referee MUST seek advice from the trainer/medical staff before sanctioning the removal of an injured player.

Organise. (Taking charge, positioning and seeking medical assistance if it is required).

When the Referee arrives at the scene, he should position himself such that he can still keep an eye on the rest of the players. In other words, the Referee should not place his back to the rest of the players when he is dealing with the injury. This is the most common fault when Referees deal with an injury situation.

In moments of tension, the Referee should also position himself so that he can monitor the technical area occupants. This is doubly important if the injury location is near to the technical areas.

The Referee should position himself near the injury location, so that he has the majority of the rest of the players, in front of him.

When it is safe to do so, the emphasis should always be on the injured players receiving treatment after they have left the field of play, rather than whilst they are on it.

Whist an injured player is being assessed, or receiving any immediately required emergency treatment, the Referee should stand a couple of paces back from the scene, in a position so that he can communicate clearly with the participants, and in such a way that you can also keep an eye on the rest of the players whilst overseeing the assessment of the injury.

The Referee should allow the trainer/medical staff a reasonable amount of time to make a diagnosis/verification of the injury, but they must be reminded that no (non-emergency) treatment is allowed on the field of play.

When an injury occurs, tempers can be at a heightened state. The Referee should allow a reasonable space between himself and the medical staff. Close attendance by the Referee may on some occasions, inflame tempers.

Whilst monitoring the injury assessment, the Referee may also have to simultaneously deal with indiscipline. The priority must always be in seeking help for the injured player. Once this has been achieved, the Referee can deal with any misconduct.

Some trainers/medical staff when dealing with an injured player cannot refrain from berating the Referee. The Referee must allow the injured player to be sorted out, before taking any action against misbehaving trainers/medical staff.

Usher. (Overseeing the safe removal of injured players).

If the player does not require treatment, and is able to walk to the touchline unaided, the Referee should encourage the player do so by the shortest route. In such cases, the Referee should provide a signal towards the trainer/medical staff, to indicate that their medical assistance on the field of play is not required on this occasion.
If an injured player is able to remove himself from the field of play, the Referee should prevent any trainers/medical staff from rushing across the field of play, rather than making their way around the boundaries to reach the injured player as play resumes.
If the player is unable to make his way to the touchline unaided, or if he requires a trainer's presence, the Referee should signal for help with a clear one arm-beckoning wave, vocal instructions and if necessary, use of the whistle to attract attention.
Once the (one or two permitted) medical staff have arrived, the Referee should allow a reasonable amount of time for them to assess the extent of the injury.
If the injured player does not require a trainer/medical staff, and intends to remain on the field of play to recover, the Referee should allow a reasonable amount of time for recovery, prior to recommencing the game.
If the Referee is advised by a Doctor or other medically qualified person that a player's injury is so bad, that it would be harmful for that player to continue playing, the Referee should ask the Doctor (or other medically qualified person) to decide whether the player can be moved or not, or whether the player is able to leave the field of play.
If the trainer/medical staff considers that the player cannot walk off, they will advise the Referee, who will use the two-handed signal for a stretcher. A seriously injured player should only be moved from the field of play on the trainer/medical staff's authority. A Referee is not medically qualified to make this decision.
Referees MUST stay with the injured player to ensure whatever action is required is completed as quickly possible and that the trainers/medical staff leave the field as quickly as possible, taking the shortest practical direction from the field even if this is in the opposite direction to the technical area.

Start. (Starting the game again after the injury has been seen to).

Play can be restarted once the injured player and any trainer/medical staff have completely left the field of play.

The Referee can use a combination of arm and vocal communications, to signal to the injured player that he can re-enter the field of play.

An injured player may only return to the field of play after the match has started

An injured player may only re-enter the field from the touchline when the ball is in play.

When the ball is out of play, the injured player may re-enter from any of the boundary lines.

If play has not otherwise been stopped for another reason, or if an injury suffered by a player is not the result of a breach of the Laws of the Game, the Referee restarts play with a dropped ball

The Referee alone (or if nominated, the Assistant Referee or Fourth Official) is authorised to allow an injured player to re-enter the field whether the ball is in play or not.

When play has been restarted, the Referee must be very careful when he allows the injured player to return onto the field of play. The Referee should wait until the play action is away from the vicinity of the waiting player before signalling him to enter. The oncoming player should not become immediately involved in active play, as this may generate problems.

The Referee (or if nominated, the Assistant Referee or Fourth Official) must check that any bleeding players have been treated properly before they are allowed to enter the field of play. A player cannot wear clothing with blood on it, and players uniforms contaminated with blood should be changed. The player's equipment should NOT be rinsed out and re-worn.

The Referee should always read the Competition Rules. In some competitions, the Rules forbid the Referee from adding on time at the end of either half of the game for injuries or any other cause because of the tight schedule of games being played on many grounds.