Injury Prevention

Mark Tesoro: Hello. My name is Mark Tesoro, and hopefully you could see what's going on here. We are looking at a presentation that we have developed for Falls Prevention. Typically, we do this in front of people to make the presentation a little bit more enjoyable and interactive and non-threatening but with COVID, we're trying to do our best to do as much online as possible, and to make all these presentations available to the public as much as we can. Hopefully, we'll be back in front of people in the near future, because it is more engaging and interactive when you have an audience in front of you that you can ask questions. However, I will ask questions during this presentation, because I think it helps to at least come up and think about some of the questions that I pose. I think it makes it a little bit more engaging.

So as we begin here, you'll see my screen and I'll be putting different things up on the screen. This is a program that we developed a while ago. It's had a couple of different names but Step Smart and Stay Active Saving Lives Through Falls Prevention. That may sound a little bit ... Saving Lives Through Falls Prevention might sound a little bit trite, but it's really very, very true. You'll see in a moment here that it's truly is saving lives through falls prevention. My name is Mark Tesoro. I work for Lee County Trauma Services District, along with a number of other individuals who volunteer to present this information to a variety of different audiences, and we're just very excited to get out there and really help people stay safe. I will tell you that the ... if I put you to sleep, which I'm going to try my best not to, but the entire presentation, the two main objectives or points of this presentation, I will tell you right now.

There's two sentences that sum up this whole presentation. The first sentence is, "Falls are not a normal part of aging," and I'm going to say that again, "Falls are simply not a normal part of aging." Do not let anybody tell you that you're turning a certain age and it's part of growing older, and that you're going to fall and that's just the way it is, that's not the case. The second sentence is that they're preventable. Falls are preventable, if you learn how to adjust your lifestyle and make some adjustments, you can prevent yourself from falling. So this is not destiny and it is definitely something that we can control, and that is something under our power to make better, so let's just dive right in. If I can get the presentation slides to work correctly, here we go. So who we are? As I mentioned, we're local volunteers and health professionals going out there among the population.

We are all concerned about falls and falls prevention. There's actually a 501(c)(3) that was developed, a nonprofit organization that helps distribute this information. It's called stepsmart.org or dot com. You can go either way, I think and take a look at it. We deliver education. This is not selling anything. This is delivering education to the public on the very easy ways to prevent falls and they are preventable, as I said. So unintended falls can be prevented, believe it or not. So why do we even bother discussing falls? Well, they're the most serious common and devastating injuries and problems among the senior population, period. Why should you care? One out of four seniors fall each year, 20% of those who do fall, fall so badly they're hospitalized, and half that are hospitalized pass away within any given year.

It is the leading cause of death from injury for seniors. It is ... Again, I'm giving you this information not to alarm you, but to let you know. I think knowledge is power and I think it's important that we let people know the significance of the issue. If there was ever ... like the COVID, if there was ever an epidemic, this is certainly an epidemic. It's the leading cause of injury death for seniors is falls. Nationally, we see the numbers going up. There are significant numbers of folks, and this is data from 2019. Although it only goes up to 2016. There's a data lag there, but we see traditionally that, believe it or not, women fall more frequently than men, but men who fall less frequently die from their falls more frequently, but we see more mortality among men than women, but overall the trend is that these are increasingly ... an increasing situation and not a decreasing situation.

Most people think that falls ... the greatest number of unintentional deaths are from motor vehicle crashes, but you look falls are right in there with motor vehicle crashes in terms of number of people who die from them every year in Florida. Poisonings are leading the pack, the way what poisonings are, which some people always ask why poisoning is so much far ahead. The poisonings, that's how the state represents the opioid epidemic. So that certainly is a major issue, but really, statistically, falls are as deadly as motor vehicle crashes in this state. So it's something to be aware of. It's something that people are most often surprised about, 60% of our injury deaths are from falls. A four day stay for fall related injury in the nation, actually, this is an average in the nation, is $61,232 for a full four day stay.

That is well over $15,000 a day. So when we start talking about things like a couple of hundred dollars for installing grab bars or canes, or walkers, or putting out some money to do these kinds of things, I want you to think about a four day stay for $61,232. That couple of hundred dollar items starts looking very, very reasonable in the grand scheme of things. I'm not sure if anybody has heard the term of aging in place. It's kind of a buzzword. It's kind of a ... well, a common term at this point. Aging in place means that you want to grow old, where you live. So most people want to age in their home. They want to age where they're comfortable, they know where their furniture is, they know where they keep all their dishes and silverware and glasses. It's just more comfortable to age in place, where you're located currently in your home.

When you have what we see here, 57% of folks discharged after a fall to a nursing facility, and only 11% returning home, holy cow, there goes your aging in place, really, right out the window. So the Smart Money is really to try to take advantage and address these falls early, and try to stay as independent as possible so that you can age in place, but falls don't make that a possibility. So we're going to do our best to try to address these falls and make sure that we are safe. So where do falls happen? 60% of the time, falls happen at home, at home. Home is a dangerous place. So we want to keep you home but certainly homes are where falls tend to happen most frequently. So we're going to concentrate on that 60% of the time in home, 30% of the time in public places. What do we mean by public places? Well, places like restaurants and bars and parking lots. I don't know if anybody has tripped over the parking bumpers that are in the parking lots, but I certainly have.

In fact, that's one of the areas that we've tried to address going to businesses and asking them to remove those parking bumpers, because they are a tripping hazard. So that's what they mean by public places, to tripping and slipping in different locations, supermarkets, et cetera, and 10% of the time in health care institutions. Those are hospitals and nursing homes. So we're doing pretty good in the hospital areas, but we could always do better, but that 60% at home, that's what we're going to really focus on because that's what we can address the easiest and most likely where something will occur. So here's the good news, we've gone over all the scary, horrible numbers but the good news is that falls are preventable, as I said at the front end of this talk, and they are not a normal part of aging.

Falling is actually a symptom of something else going on, something else in your body that's amiss. Most people age, in a way and you should be aging in a way that you're not falling. If there is a falls occurring, there's something else happening that we need to understand and identify. The way I like to think about it, sometimes there are so many issues surrounding falls, that it's hard to understand what is actually causing a fall. So I try to break it down into three areas in particular, three risk factors. So there's a physical risk factor, physical conditions that cause falls, right? There's certain physical conditions that you have, medical conditions, that kind of predispose you to have a fall more than the general population. So there's that little bubble and then there's a bubble for behavioral risks.

So behavioral risks are things like decisions that you make. You could be overestimating your abilities and doing things you shouldn't be doing. Not listening to your doctor. Not using a cane or walker. Deciding not to take your medications correctly. Those kinds of behavioral things also cause falls. Then, there's environmental risks that cause ... that we mentioned earlier, things in the environment that cause falls. Not necessarily outside of your home, but even inside your home, throw rugs and those kinds of things are environmental risks that cause falls. So we may need to adjust or tweak each one of these bubbles a little bit, but if we have to, we tweak these bubbles, to prevent ourselves from falling. So there are certain risk factors and there are conditions that cause people to fall more frequently than others. There's certain ... we can break those bubbles down into a little bit more detail and address things specifically.

So what kind of things are we going to talk about in this talk? Well, we're going to talk about strength and balance. Obviously, that has a huge issue in preventing falls, and most fall prevention talks only talk about strength and balance. So I really, really like this talk because it talks about much more than just strength and balance. We talk about medications and medication side effects. Those certainly have an issue and affect people's balance and cause them to fall sometimes. We're going to talk about vision. We're going to talk about ... Vision, if you can't navigate through your world correctly, guess what, you're going to increase your chances of falling. We're going to talk about the home environment. We said just a minute ago that 60% of falls happens in the home, so we have to talk about the home environment a little bit and we're going to talk about the history of falls.

If you've fallen in the past, it increases your chances of falling in the future, unless you make some adjustments. So we're going to talk about having a history of falls and how to avoid and break that cycle of falling. So that's why I really enjoy this talk is because it talks about, well beyond just talking about exercise and strength and balance. It talks about a lot of other factors that cause falls. So one of the first things we're going to talk about is vision and hearing. With vision, you want your vision to age in a healthy manner, along with the rest of you. The American Ophthalmological Society suggests that by age 40, you have what's called a full vision screen. What is a full vision screen? A full vision screen is not just getting your prescription check. A full vision screen is getting a dilated exam regularly, annually, which checks for glaucoma, cataracts, diabetic retinopathy, macular degeneration, all of those conditions, why?

Because if you identify something early, and get medication on board early, guess what the more effective that medication is. So the quicker you can identify and treat, the more effective that medication is. You want your vision to age in a healthy manner again, so you can navigate through your world correctly. Hearing again, is also a very, very important part of not falling. Hearing and ear issues are certainly related to balance, and the research shows that if you address hearing issues quickly, your brain has a chance to compensate and adjust, let's say hearing aids or something, or devices of some kind to make those devices more acceptable to your brain so they're not as awkward or uncomfortable. Also, hearing has also been associated with memory and preventing dementias and those kinds of things to keep those areas of your brain active. So having a regular hearing exam as well, to check your hearing is crucial in helping prevent falls.

There are other medical conditions, there's certain medical problems, certain physical conditions that predispose you to fall more frequently than the general population that doesn't have those conditions. It doesn't mean you have to fall if you have these conditions, but certainly your chances of falling are increased. So what are these conditions? Well, one of them is stroke. For folks who have had a stroke, or if you know somebody that's had a stroke, though folks that have strokes tend to have one side of the body, tends to be a little weaker than the other side of body. Usually one side of the body is more affected than the other, depending upon where the stroke occurred. So what does that mean for falls? Well, you may recover a lot of that strength and that vision in that certain ... not half of the body that was affected, to the point where you don't even recognize it.

You'll always be a hair different on one side than the other. It might be a hair or fraction difference in terms of where your limbs are in space and how high your foot is off the ground and how your vision is on that one side? That just little bit of difference between one side and the other is just enough to potentially have you fall a little more frequently than somebody who hasn't had a stroke. Blood pressure problems, certainly related to false. When I mentioned blood pressure, people immediately think, "Oh, high blood pressure," but guess what, when we talk about falls and falls prevention, we have to think high and low. Low blood pressure is as bad as high blood pressure. Low blood pressure can make you as dizzy and nauseous and confused as having high blood pressure. So don't think just in one direction, when we talk about blood pressure. We're thinking high and low.

Neuropathy if you've heard that term before or not, I'm not sure. It's a neurological term used to describe the signals from your brain and spinal cord, not quite getting to the extremities correctly. What does that mean, that sometimes people with neuropathy tend to have pain or pin pricking feeling in their fingers and their toes. Sometimes they're not quite sure where their limbs are in space. Again, they're not quite sure how high their foot is off the ground or where their body is kind of located in space and because of that, those folks with neuropathy, they tend to fall a little more frequently than the general population that doesn't have neuropathy. Dementias, especially progressive dementias like Alzheimer's. Sadly, those folks, they tend to fall more frequently because if you're not quite sure what a chair or how a bed is used or how a couch is used, you tend to fall a little more frequently.

So these folks tend to fall out of confusion, and out of, not quite knowing how to utilize or what each object is, sadly. Then Parkinson's, Parkinson's is very associated with ... Parkinson's disease is very associated with falls. If you know somebody with Parkinson's or have Parkinson's yourself, you'll know that there's an essential tremor associated with Parkinson's. There's also a rigidness and a stiffness associated with folks with Parkinson's when they walk. So they do actually what's called a Parkinsonian Shuffle, where they tend to shuffle their feet instead of lifting their feet off the ground. A lot of the medicines they use actually, to treat Parkinson's are designed to actually loosen you up a little bit, make you less stiff but when you're very, very stiff with Parkinson's, and you do trip, you're not fluid enough to catch yourself on a fall and you tend to fall very frequently, because you're stiff and rigid.

So again, these are not necessarily exhaustive lists of things that ... conditions that cause people to fall, but certainly they're kind of the heavy hitters that we see people having trouble with falls that have. So if you are aware of having these conditions yourself or know somebody that has these conditions, they're at a higher likelihood of potentially having a fall, just in that physical bubble that we were talking about that we need to try to address as best we can, and adjust medications and do those kinds of things. So imbalance, imbalance is the first thing we think about when people think about falls and falls prevention and most people talk about it. It's true, balance is a huge, huge issue but what I concern myself with more often is that when people fall, and they lose their balance and they fall, they're scared.

Rightfully so, we saw the numbers at the beginning of this talk and the numbers are scary, so people get scared. What they tend to do is they tend to relegate themselves to the house and put themselves on a couch and stay there out of fear of falling again, thinking that they're going to do themselves a favor by keeping themselves safe. When in actuality, that is a self-fulfilling prophecy to just fall again. Why? Because when you relegate yourself to the couch, out of fear of falling again, and not do what you were doing before, when you were active, you start to atrophy your muscles, you start to get less tone, you start to lose that skill set you had before and what you're trying to prevent by staying on the couch, you're actually causing because you will fall again, because you've lost those skills and that muscle tone and all of that.

So what we ask people to do is to, after a fall, obviously recover and do whatever rehabilitation you need to do, but to get back into what you were doing before. To get out and stay active and not get yourself and not relegate yourself to a couch, but to stay active and involved. Very, very important. Also, you do not need 20 years of medical school to identify somebody with bad balance. What do I mean by that? Clinically, when I was working more clinically up north, we used to almost identify somebody with bad balance by how they came to us from the waiting area. If I call somebody's name, and they walk towards me, going from piece of furniture to piece of furniture holding on as they're coming towards me. Guess what, it doesn't take a rocket scientist to sit there and say, there's something going on there or if somebody is standing with a very, very wide stance or having to lean on something while they're talking to me, certainly that night, that it would represent potentially a balance issue for me.

Two ladies walking arm in arm, very often, I know that can be a very European thing, potentially but certainly could represent somebody trying to hold each other up and balance each other. So what I suggest to people, if you see these things, I challenge you to say something to somebody. If you see somebody that you know doing these things, say something and although that might be an awkward conversation, you could say something like, "Gee, I noticed, you look like you're having trouble with your balance. Have you talked to your doctor about your balance?" As simple as that. Now, like I said, while that's maybe an awkward conversation to have, it's a much easier conversation than visiting them in the hospital for a four day stay for $61,232. So it's up to you but I challenge people to say something and talk to them about speaking to their doctor.

What they can say also is that they would go to their doctor and ask their doctor for what's called a full balance evaluation. A full balance evaluation would be a prescription that your doctor would provide you if you're worried about your balance, to go and see a physical therapists, physical therapists are the experts in balance. You would get a prescription from your primary care doctor, get a prescription for physical therapy, for balance, strictly for balance. It wouldn't be physical therapy for getting your know ... if you had your knee done or if you've had your shoulder replaced, or things along those lines, there's physical therapy just for those kinds of rehabilitative issues, but this would be physical therapy, just for balance, just to assess your balance. We typically, when we are not in a COVID situation, go out to communities and do what's called a balance screen, which is a very brief, maybe five minute screening of how your balance is.

Then, we give a printout to people to kind of identify who's potentially at risk and who's not at risk but eventually, if their balance is a little bit off on that screening, we asked them to go to the doctor and ask for a full balance evaluation by a physical therapist near you, so that's the process, so when people say, well there's nothing I can do, what am I going to talk to my doctor about? Well, actually, yes, there is something you can do and there is something that doctor can try to do. Those physical therapies thus can give you exercise for different muscle groups. They can give you a training regimen to kind of bring you from a potentially unbalanced stance to a more balanced stance so that you're equal on both sides of your body, and help you develop those muscle groups that potentially are weak on certain areas.

Medication and medication side effects is something that most talks and most presentations on balance and falls prevention don't even address but medication side effects are tremendous. Very, very big issue. I'm going to cover them kind of quickly, and I don't to be too burdensome on the medications, but addressing medication side effects is a tremendous issue in helping prevent falls because sometimes people have their medications and they feel some side effects and they think to themselves, well, this is the way it's going to be for the rest of my life and I'm just going to push through it and if I'm dizzy with this medication, well that's it and that's what I'm going to have to deal with. We're here to say that's absolutely wrong. If you're feeling side effects on your medication, you need to do something about it to adjust those medications and fix those side effects so that you're not at an increased chance of falling.

So some of the, let's say behavior altering medications or thinking medications, I'm not so worried about the fancy names of them, but the brand names you should really remember, there's some pretty common ones, Valium and Ativan and Zoloft and Prozac and Haldol, Seroquel. They potentially can cause ... like what we were saying earlier, they could potentially cause side effects. It doesn't mean you have to have the side effects, but the side effects could be sleepiness or dizziness. We said that either very high blood pressure or very low blood pressure can be an issue, so guess what the cardiovascular medications can be a bit of a problem potentially. So things like Toprol or Vasotec or Zestril can cause fainting upon standing, if you are taking those medications, either incorrectly or you're feeling the side effects of those medications. Other medications, heart medications, like digitalis.

Something that's very interesting is that, it's not necessarily your prescription medications. Benadryl for example, over the counter medication can cause a great deal of sleepiness. I know when I'm working with my dad right now, who's older and he was sleeping and sleeping and sleeping, and we could not figure out what was going on, we went through all his medications and nothing seemed to be ... he was taking everything appropriately but then we realized that he was taking all kinds of Benadryl and it was really causing him to sleep. So certainly, be aware that it's the over the counter medications, as well as the prescription medications that you need to be aware of. Certainly sleep medications like Ambien or pain medications like Oxycontin cause a great deal of sleepiness and cause people to fall.

If you're a diabetic, if your insulin level is not checked, you need to make sure that that blood sugar is okay, and that you're not inadvertently getting yourself dizzy or weak, all of these things can cause people to potentially fall. I do like to mention alcohol, because alcohol is one of those things that people are aware of, that can be a problem, but I'm not quite sure why the doctor tells you not to have alcohol with your medications. It's not that the doctor doesn't want you to go out and have a good time. The doctor wants you to go out and have fun but the alcohol ... what the alcohol does, it exacerbates all of the negative symptoms that we're talking about and none on the positives with the medications. So if you're on sleep medication to allergy medications, or sleeping medications and if the side effect is sleepiness, guess what, the alcohol will increase that sleepiness.

If you're on any kind of antidepressants or anticonvulsants, and the side effect is impaired mental status, alcohol increases that impaired mental status. If you're on high blood pressure medication and dizziness or fainting upon standing, alcohol exacerbates or makes that dizziness or fainting upon standing even more likely. So alcohol will certainly cause the worst parts of those medications to occur, instead of the best parts. I always ask people, who in the room has a list somewhere with all of their medications on it? I usually get three quarters of the room, have their hands raised usually that have a list somewhere, a piece of paper somewhere or something that has all their medications on it. Then, I asked typically, who has it with them, who has that list with them right now, right now as we're sitting here? Then, when they raise their hands, I would say about a quarter of the room may have it with them right now.

What I need people to do and what I'm going to ask people to do is keep a list of all your medications somewhere, but most often keep it on you. A medication list that's in the junk drawer in the kitchen is not going to do anybody any good. You need to keep it in your purse or your wallet or on you and take it to every single doctor visit you go to see, not just your primary care doc but cardiologist and rheumatologist and oncologists and dentists and everybody, nobody should be guessing what you're on and especially a lot of the names in the medications are very complicated. So certainly, you don't want to be guessing or you don't want your doctor to be guessing what medications you are on, so bring it to every single doctor visit you go to and it will definitely help you.

I also ask people who in the room knows a pharmacist personally, or actually just professionally, who knows their own pharmacists and most people raise their hands, maybe half the room, maybe raise their hands. I tell people to get to know their pharmacists, really, because they are the experts in medications. Even at the hospital here, we rely on our pharmacy staff to talk to us about all the changes and the new medications that come out. They are really the experts in medicine and things are changing constantly. Also, to use one pharmacist. If you use multiple pharmacists, sometimes pharmacist A, doesn't know what pharmacist B, doesn't know what pharmacists C is giving you. Sometimes there's a conflict between medications and that flagging system that would be put in place ... that would alert the pharmacist if you're using one pharmacy, is kind of thrown out the window, that they might not be flagged.

There might be some significant problems. So we typically ask people to go to the one pharmacist where their most expensive medication is cheapest and use that one pharmacist so that they're safe, and to make sure that if there is a conflict that it is flagged with your medications. Always ask about how to take your medications correctly, how much, how often, when do you take it? Why do we say this, because the better you take your medications, the less likely you'll have the side effects that can cause you to fall. Sometimes it's very, very tricky to have people take their medicine correctly, because it's hard. Sometimes it's hard. There's medications that require you to have a full stomach for. Some, you're supposed to have on an empty stomach. Some, you're supposed to take milk beforehand. Some you can't take with citrus.

Anybody who's a medical person is not going to yell at you for not taking medication correctly, because it's challenging, but certainly the better you know how to take your medication and the more regularly you take it the same way each time of the day and each way you take it, is consistent. It's going to keep those side effects from occurring, and potentially reduce false. Footwear, most conversations about falls and falls prevention don't even talk about footwear, but footwear is implicated in about two thirds of the falls they see in the emergency departments. Footwear is a huge, huge issue and I usually ... when I'm in front of people, I usually ask people, what kind of footwear causes people to fall? What kinds of shoes cause people to fall? Think about that for a second. Well, most people raise their hands and say flip flops.

Absolutely, flip flops are an issue, why? Because anything that slides on really easily comes off really easily. So flip flops are certainly an issue, some folks sometimes mentioned Crocs, I don't know if you know what those shoes are. They're kind of rubber shoes but there's absolutely no support in Crocs. Crocs cause people to fall because they kind of crush in on themselves and their feet kind of crunched down and there's no support. There's also, ladies I'm thinking of a shoe, high heels are an issue. Some people tend to be fashion victims and wear nine inch stiletto heels. That's not exactly conducive to not falling so I would recommend a lower heel height or something with a wider heel, if you have to wear heels. There's also shoes that are called loafers or slick bottom slippers that cause people to fall because of the slickness of their sole, is very, very slippery and people tend to fall from that.

I have seen men in particular, buy shoes with as much steel as they possibly can put into a shoe. They will buy shoes that are more like boots that have steel toe, steel shank, steel heel, as much steel as they can possibly put into a shoe, thinking that it's going to help them prevent them from falling. In actuality, a shoe like that is so heavy that the weight alone is dragging those shoes around with you and those boots around with you. So certainly the weight of a shoe is important as well. I'm going to show you a shoe here that is a great foundation to not fall and it's not necessarily a particular brand, but there's certain features of a shoe that is better to keep you from falling than not. So first of all, what do we see? Well, like I said it's a lightweight shoe. You do not need to have a heavy, heavy shoe.

Certainly a lightweight shoe is better than a heavy shoe. I would sacrifice weight for anything else, a lightweight shoe is very helpful. A slip resistant sole, we said not like a slipper or a loafer. A nice firm midsole inside to keep them nice and stiff, what's called a low heel height here for ... not a stiletto heel right, so we get a high heel collar around your ankle to give some support, so it's nice and tight, and seams that are smooth and free of any kind of major stitching so that you're not rubbing and constantly fixing the shoe, and a good tightening fastening mechanism up front and that can be Velcro or laces. Very often people say to me, "Oh I have a pair of sneakers. I'm fine." Just because you have a pair of sneakers doesn't mean that you are fine.

In fact, some sneakers have a rounded heel and they are very, very lightweight. Those tend to be running shoes. So you want a heel that's kind of squared off and a little bit wider. Also, I don't know if you've gone sneaker shopping lately, I'm of an age where I remember having just maybe one pair of sneakers, possibly two. If you go sneaker shopping now, every single activity has its own sneaker. So there are running sneakers and there's basketball sneakers and there's cross trainings sneakers and there are dancing shoes and Zumba sneakers, and there's all kinds of sneakers for every single activity. So it's a lot harder than you would think, but if you look for these kinds of features in a shoe, in a sneaker, for example, regardless of the brand, you're doing yourself a favor. That is a good foundation to not fall. Assistive devices, canes and walkers. Three things need to happen for an assistive device to work.

When I'm with an audience out in front of them, I asked them usually, what is the first thing that has to happen for an assistive device to work, what has to occur for a cane or walker to work? You've got to use it, you've got to use it. If you do not use a cane or walker, everything else is thrown out the window. So I think a lot of times people think about what a cane or walker is and they're thinking about something that used to be a cane or walker and canes and walkers in the past, walkers, for example, are thought of very frequently as this steel thing with some tennis balls on it that somebody drags behind them and not very useful. That is actually an inaccurate thinking of how walkers are these days. If you look at a walker now, there are some walkers that are absolutely unbelievable.

They have tires. They have brakes. They have storage. They have seating. They have cupholders, that it is a much, much more useful product than what used to be, so don't be caught in the stigma of not using something because it makes you look old or it's not something that is effective. A walker today is not what a walker was, years and years ago. Same thing with a cane, the days of a steel pole kind of thing are gone. Canes now are decorated and they're beautiful. They have feet on the bottom that stand up on their own. They're just very, very useful device and good looking compared to what used to be. So I always applaud people in the room that either bring their cane or walkers with them, because they frankly, are the smartest people in the room to be using them because we saw what the numbers were.

So if it gives you even a 10th more security or in comfort, and stability, why not use it? It's crazy not to. So I tell people all the time, the first most important thing you can possibly do is get comfortable with that walker, be comfortable with yourself. Especially here in Florida, there's enough people using these devices, where it doesn't ... it's not shocking to see somebody using these devices. So use it to keep yourself safe and out of harm's way. So the first thing that has to happen, you got to use it. The second thing that has to happen is it's got to be fitted to you. Very often canes or walkers are given to people who they are just handed over and said okay, go on your merry way but if it's not fitted to you correctly, if it's way, way too tall for you, where you're reaching up for a cane or walker or way too small for you where you're crunched over or hunched down to use the device, it is going to probably cause a fall rather than prevent a fall.

So certainly you need to have that device fitted to you correctly. You need to make sure it's at the right height and the right level so that you're not either very reaching over or hunched over or reaching up for the device. So that's the second thing, it has to be fitted to you, and the third thing is you have to know how to use it correctly. Again, somebody should teach you how to use these devices. Sometimes I see people in the hospital walking with a walker, way, way reached out in front of them, trying to walk with a walker, instead of walking into the walker to get that stability and that sense of security. Same thing with the cane, they're supposed to be using on the correct side of the body when they're using it. So again, if it's not taught how to use correctly, could actually cause a fall, rather than keep you from falling.

Three things that need to happen, you got to use it. It got to be fitted to you correctly, and got to know how to use it correctly. Those three things happen, all of a sudden now, you're keeping yourself in a much better safe position to not have a fall. Living space and environment. We said 60% of the time, something happens, it's going to happen, the fall happens, it's going to happen in the home and there are about a thousand things that can cause a fall in the house. When I'm out in front of an audience, I usually make them give me at least a couple. So think about some of the things in the home, that cause falls. If you think about it, the first thing that usually pops into everybody's head is throw rugs. So certainly throw rugs are an issue, but if you have to have a throw rug, there's a way to correct it.

If you use double sided tape to put those throw rugs down, if you put a slip resistant pad, that's very much like shelf liner, it's kind of rubberized that helps keep a rug in place so if you have to have a throw rug, certainly make it secure. People come up with often, very often things like ... what else causes falls in the home? Well, let's think. Well, lighting. Most people don't realize that lighting is a tremendous issue for keeping people safe. If you have bad lighting, guess what, your chances of falling greatly increase and I'll tell you what, I tell people this all the time, I say to people, ladies and gentlemen. You should never cross a dark room to turn on a light ever, ever. It should never happen. You should have a light right near the door. You should have a light right near your bed.

If you are older, very often, you get up in the middle of the night to use the bathroom, I tell people to have nightlights from the bedroom to the bathroom like a runway. There should not even be an issue. It's the safest, cheapest thing you can do to keep yourself safe. Very often, there are thresholds between rooms, that's a lip that goes up and down. You might have to designate that or be aware of that. Sometimes people say any kind of water on a slick surface in a bathroom or a kitchen is obviously a fall hazard. My parents have a refrigerator that has an ice maker. I would say one out of every 10 ice cubes hits the floor and makes a little puddle and what do we have, then we have a potential fall hazard. So it's kind of thinking and being creative. Pets, absolutely, pets can cause an issue.

Very often people are very much aware of very large pets being an issue. Frankly, kitty cat will take you down as quickly as a great day. In fact, the smaller pets go right between your legs almost more than the large pets. Large pets tend to be more lumbering and slower moving, believe it or not. The smaller pets are the ones that kind of jump on you and run between your legs and make more of an issue, but not to say that I'm against pets. I think they're wonderful but be aware, those kinds of things. We at our group have a list and if you go to our website, the Step Smart website, you will find ... stepsmart.com, you will find a list of 100 items in the home to think about. Now, we don't expect people to go home and look at every hundred things, but if you make just a few adjustments, you will find yourself being much more safe in your home and again 60% of the time, that's where likely something will happen. Does anybody know what room of the house is the most dangerous?

Well, some people say the kitchen but actually the bathroom is the most dangerous room in the home, 70% of your falls at home are going to occur in the bathroom. So the hand ... we're looking at things like handheld showers, grab bars, not the suction cup grab bars but if you're going to use grab bars, if you do the math and do the physics of it, a suction cup is not going to hold your weight up if you're coming down at full speed. So we highly recommend getting a contractor or licensed contractor and putting those grab bars into the studs of a wall that give you the support you need. If you need a shower chair, you get a shower chair. Sometimes you need a raised commode to make getting on and off the toilet easier with some grab bars around there as well. Very, very helpful.

A nice shower rug that's not sliding around so that if there is water on the floor, that you're not slipping on that water. All these things are tremendous, tremendous if you do nothing else, but check out one room in the house, check out your bathroom. The bathroom is an unforgiving room. Every surface on the bathroom is hard, so that we can clean it but it's unforgiving if you have a fall, so please check out your bathroom and make sure that it's safe. Another place right after bathrooms are staircases that people have issues on. So we suggest that people get handrails on both sides of the stairs, especially an outdoor. We want lighting at ground level, you can see there is some lighting there, in that picture there with ground level. We want to have light switches at the top and the bottom so that you're not going up and down dark staircases. If you are worried about your balance on stairs, I have a good little trick to kind of keep in mind.

Very often, I had a doctor I worked with, who said think about when you have fallen on a staircase. You have likely fallen on the very top step, or the very first step but very rarely do we fall in the middle of a staircase and why is that, because we get a little bit of momentum going and we get a little bit of a rhythm going, but because we're rushing, we tend to rush on that first step or that very last step. Frankly, if there's going to ... a fall to occur, it will occur on that very first step or that very last step, probably. So if you're worried about your balance, pay particular attention to that very first step or that very last step, because likely, that's probably where something will happen. So that's just a little heads up, level of activity. This is where people usually go, "He's going to tell me, I need to exercise and I hate to exercise."

Well, you don't need to be training for a triathlon to improve your balance and improve your strength. There's actually one activity in particular that's known and been proven to help balance but we're going to ask that one a little bit, but if you just get yourself out of what's considered a sedentary lifestyle, and the definition of a sedentary lifestyle is less than 25 minutes of activity a day. So if you can break 25 minutes of activity a day, you're doing okay in my book. Now, that's a minimum. You should do way, way more than 25 minutes of activity a day. Sometimes we see people here in clinic at the hospital even, they have a hard time going to the mailbox and back and we understand that, but certainly more than 25 minutes of activity a day. The activity doesn't have to be organized sport.

You don't have to necessarily go to a gym and do these things. I consider activity, anything that gets your heart rate up for more than 25 minutes a day. So what would that be? That could be gardening. That could be walking. That could be doing laundry. That could be doing housework. That could be doing ... I think organized, doing different activities, certainly encourage you to continue and do things on a regular basis, but they do not have to be organized activities, if you're kind of, prefer doing activities on a solo level. The most ... if you've been thinking about it, the most proven activity to help with balance that's been documented has been Tai Chi, believe it or not. Tai Chi, I don't know if you're aware of Tai Chi but it's an Asian exercise routine where it's very slow. You shift your weight back and forth, and forward and back and it's a very deliberate movements that help you with your balance and your strength.

Tai Chi is not necessarily the only thing that will help you with balance. It just tends to be one of the things that have been proven, but I think if you do any regular exercise on a regular basis, that gets your heart rate up and your balance going, you're going to do yourself a favor. One of the last things that we're going to talk about and you see the avoid falls thing is complete on the side here, is that safety. We need to make sure, where safety ... remember safety and take care of ourselves. If somebody falls, if somebody with horrible, horrible balance falls and somebody with very bad balance tries to pick them up, now, what do we have? Now, we have two people on the ground that need assistance. So you need to make sure that you're safe, especially if you're with somebody else who's larger than you.

So if somebody falls, and they're larger than you, I need you to call 911 and I want you to tell the operator that you need what's called a lift assist and a lift assist tells the operator on the other line that the ambulance with a fire engine is going to come and they're going to help lift somebody up and not necessarily transport them, but to lift somebody up off the floor for you. They will probably do an assessment anyway, while they're there to make sure everybody is safe. If you ask for a lift assist, it goes a long way and it keeps you safe from hurting yourself as well and having two people on the floor. One of the things we always like to try to talk about is so what happens after you fall? So you fall and then now, what do you do? Well, there are smart steps to take to keep yourself safe.

One of the first things you would want to do if you do fall is you want to do what's called a self assessment. That's just the fancy word for how badly I've just fallen, how badly I've hurt myself. If I think that I've just scared myself but I'm okay, what I need you to do is I would suggest that you ... if you're on your back, you're not going to be able to throw yourself back up and start walking, so if you're falling and you're on your back, you're going to want to roll onto all force and crawl over to a good solid piece of furniture and get yourself up on that solid piece of furniture and catch your breath. In fact, I'd still call 911 just to make sure you haven't fractured anything, because sometimes you could fracture something and you really don't even feel it until maybe a few days later. Then you realize that something is on, a problem.

You also, because you want to make ... if you do that assessment and you realized that you actually have hurt yourself to a point of being in intense pain and you've really done a number on yourself, well, my goodness, you call 911 or if you don't have a phone with you, you make as much noise as you possibly can so that people are aware that you have fallen because sometimes people ... there are rumors about people who have fallen and they are laying there for quite a while. I will tell you those are not necessarily rumors. People sometimes fall and they do lay there quite a while. So you really want to have a phone near you or on you, at almost any given time. Either keep it very, very close to you. A lot of times people wear a fanny pack of some kind to keep a phone on them but try to keep a phone within reach and if you do not have a phone, you make sure somebody is aware, you make noise or scream or yell.

I've actually heard of people actually using also their keys on their ... the key fob for the car and pressing the alarm on the key fob, so that people know that there's a problem and if you do have one of those devices that are ... you press the button and it's an emergency alert device, certainly use that as well. Those are the procedures to kind of do, if you do happen to fall. Falls are going to be a problem now and they continue to be a problem, but they're not inevitable. Like we were saying there are ... we've given you a ton of things that I think you ... again, not rocket science but just to think about and keep yourself safe, and things that are not surgical treatments to kind of keep yourself from falling, but very doable, doable things that keep yourself safe, and they'll continue to be a problem. I mean, we're growing older each day. So, it's not going to go away.

So unless we do something now and take action now, we are going to have a problem later, so we're going to take action and a very, very easy things to address some of these falls. We want to do a quick review, so annual physical exam, things you can do today, literally to change your chances of falling. Annual physical exam should be a no brainer, should be doing that every year anyway. So that should be happening no matter what. We mentioned vision and hearing screen, a full vision screen not just your prescription check and get your hearing checked to make sure that your vision and your hearing are aging in an appropriate way with the rest of your body. Review your medications with your pharmacist or your doctor. Try to reduce those side effects on your medication to keep yourself from having a chance of being dizzy or nauseous or confused when your medications are available.

Use our home safety checklist that we have on our website, again, stepsmart.com. You will see that there are a ton of things you can do around the house to keep yourself safe, we said 60% of the time it happens at home. So make sure that home is safe. Get your blood pressure checked regularly. You do not need to have your blood pressure checked every 10 minutes, but certainly twice a day, once in the morning, once in the evening just to make sure your blood pressure is under control and again, low blood pressure is as high as high blood pressure. Commit to doing more activity. If you are not doing as much as you could, increase that level. If you could do Tai Chi, that's fine but chair aerobics is just as good, and walking is just as fine, but regular exercise that kind of gets that heart rate going is going to do wonders for you.

If you are worried about your balance and you are worried about falls, have a balanced screening and if you need a full balance evaluation, ask your doctor for a prescription for a full balanced evaluation by a physical therapist. Let them determine what exercise routine that you need to strengthen those muscle groups to keep you from falling. Doing these kinds of things today will help prevent you from falling tomorrow. So please consider them. Thank you for your time. I appreciate you listening, hopefully everybody learned a little bit. I love giving this talk, so hopefully you enjoyed it as well and we're looking forward, again, this is the website down below if you need to schedule a presentation at some point in time or would like further information on what we're talking about and what we covered.

Please go to stepsmart.com and it will give you all kinds of information, even beyond what we shared today. Thank you again and I appreciate it and stay safe and don't fall. You know how to do it now. Thank you again.

Mark Tesoro: Hello, my name is Mark Tesoro, and this is the Youth Sports Safety Program that we hold at the Lee County Trauma Services District. We have been asked to put these videos together and online so that people can have access to them, while we're in the midst of COVID-19 kind of lock down. We prefer to give these presentations in person, but as of right now we're not able to, so this is our next best way of doing these things. This is a program that I typically delivered to youth athletes, but it's certainly appropriate for coaches, for parents, for athletic trainers, I think that need a refresher on the importance of a lot of these things. So we're just going to dive right in and talk about Youth Sports Safety. It's a program that was developed by Lee County Trauma Services District along with Safe Kids, Southwest Florida, in collaboration with Stop Sports Injury Program that we're a part of.

One thing I want to mention is we're going to be talking a lot of negative things regarding sports. And there's way more positive things than negative things that you get out of sports. So please keep in mind that even though we're going to talk about negative stuff, there's way more benefits than negatives with sports. Also, a lot of times when I talk to kids about sports safety, they kind of moan and groan a little bit, because it's the safety guy and it's kind of boring, and I'd rather play than listen to the safety guy. So hopefully this is interesting and entertaining. I am going to ask questions periodically, and I'll pause a little bit for you to kind of come up with an answer in your own head, because I think the interaction is a little bit more interesting. If I was in front of people talking, I would be asking questions. So I'll give a little pause in between, to kind of come up with some answers on your own.

Also, when I talk to coaches and reps and things, sometimes they say, "Well, you're trying to get a kid not to play." And that's the exact opposite. We're trying to keep people playing hard for a lifetime. The way to play hard, and if you're interested in playing hard as athletic sport hard for a lifetime, the only way to do that is to play safe. So certainly we're going to do our best to go over what some of the things we're going to do to play safe. We're going to cover things along the lines of specifically hydration, which you probably know somewhat about but I guarantee you'll learn a little bit. Concussions, because that seems to be a big topic lately, and overuse injuries. So those are going to be the main focuses of what we're going to be talking about. So these are the numbers that we saw at the trauma services.

We started seeing uptick in issues like concussions and fractures. Fractures more than concussions. Concussions are not seen that frequently, however, they are severe when they do occur very often. So we want to make sure we cover it. But we saw this is the data that we started seeing that started this whole program and we started seeing numbers that were a little bit disturbing to us. Right now there's 38 million kids and adolescents participating in sports each year, which is a huge number, which is fantastic. And it's estimated that about three and a half million kids have some kind of medical treatment for sports related each year. So that if we do the math is about one in 10 Kids approximately have some kind of issue every year where they need to go to the doctor or the medical service to take a look at.

The important thing and the reason why we're doing this talk is because experts believe that as half of these injuries that are sustained on the field are likely preventable. So we're going to do our best and try to figure out our best as to how to prevent these injuries. Like I said, we're going to talk about the problems with sports, but there's way more benefits to sports than problems. Can you think of any issues or any benefits of sports that come to mind? I know I can think of a number of different benefits of sports, but see if you can come up with some benefits of sports. I know sometimes people think well, they certainly enhance social skills, they build confidence, teamwork. So maybe you came up with some of these but valuable life lessons, how to overcome adversity, that kind of thing.

So sports, again, way more benefits, the negatives, but we're going to talk about a couple of negatives to kind of talk about a little bit about how to keep ourselves safe and healthy. One of the first questions I ask people is who's in charge of your safety on the field? Very often, kids tell me, "Well, I had nobody to talk to or I didn't tell anybody because there really wasn't anybody to talk to." But who's actually in charge of your safety on the field? Think about that for a second. Well, there is a bunch of people actually, most often people mentioned coaches. So coaches, absolutely, somebody you should speak to if you have an issue on the field. But it's not fair to load or everything onto the coach. If you think about it, the coach is doing a ton of things. The coach is trying to organize probably 50, 60 kids on a field, pretty much. It's very often a football game or larger. They're trying to win a game.

If they're in a actual event where they're trying to play a game, they're often looking at defenses and trying to figure out how to win, and that kind of thing. They shouldn't be thinking about safety. They're thinking about what plays are next. So it's a lot to put on a coach, although the coach is very concerned, and is wonderful about making sure kids are safe. We can't put it all on the coach. And then very often, I have children or youth athletes talk to me about, well, their parents. Yeah, absolutely parents. Parents are very good resource and make sure you absolutely speak to your parents. Your parents, actually, their first obligation is to make sure you're safe and then their second obligation is to make sure that you're playing as hard as you can play and play fairly. And then very often kids will say, "Well, myself, I myself I'm somebody who, nobody's going to be a better advocate for my health and safety than me."

So absolutely, you are as an athlete in charge of your own health and safety. So they call this the athletic triangle. But I came up with something and sometimes people also think of other people that should be in this kind of modality here. And very often, there's more people. So I think it's more than just a triangle. I propose that there's actually an athletic square, because you could actually, teammates are actually in that mix. I think teammates see an issue with an athlete on the field very often before a coach, or a parent. They can see what's going on. They can see if somebody is a little bit off or not playing their position quite right or a little confused, much sooner usually when you're on the field than when you're off the field. So I would put teammates in there as well. And then people forget about the referee.

Referee is a very important role with making sure that kids are safe. So they have a very important role in that they control the aggressiveness on the field. So certainly the referee is also somebody that needs to be in there as making sure kids are safe, that if you see an issue, you go to the referee and you say something to the referee. But sometimes people forget those last couple, you might even come up with a couple of more names and people. But certainly, we're looking, we went from maybe one or two people now we have five, that potentially are responsible for your health on the field. Everybody should be getting a PPE, which stands for pre-participation physical evaluation, which is a mouthful, but really, that's just the doctor checking you out before you play sports, just to make sure that you are physically capable to play the sport.

Now, sometimes kids have things like asthma, or they have seizures, or they have sickle cell, or they have different conditions which makes their playing sports, you just have to... they can still play, but they have to be trained a little differently. And what we see with coaches very often is they'll get, the athlete will get the physical evaluation, the coach will get the paperwork and file it away appropriately. But rarely never really take a good look at it. Every coach really needs to know their kids very well. So if a kid has asthma, and they're struggling a little bit, you know that they're not holding back, that there's actually a physical issue that's causing them. Or if they have seizures or sickle cell, they're going to have an issue if you're training them the same as a kid who doesn't have those issues.

So I propose to coaches to make sure that you take a look at those pieces of paper and make sure that you know each of the kids well in terms of their physical condition and train them appropriately. There also needs to be this is really for the field and the people who are hosting the sports activity. There really needs to be something called an emergency action plan. And this is just protocols that are put in place for people to know what their roles are, in case an incident happens. It's always good to be prepared before something actually occurs than trying to figure everything out while something's actually occurring. So having detailed instructions as to what to do an emergency is very helpful. So knowing, very often, let's say an incident happens where somebody hurts their leg. Very often the first thing that happens is people crowd around the athlete. Well, who's going to control that crowd and keep the crowd at bay?

Who's going to be the person to find the parent in the stands? Who is going to meet if it's needed EMS at the gate and bring them over to the athlete and the coach. So those kinds of things, when are they're spelled out pretty clearly work very, very well, when it's really decided as to who is going to be doing what in case something happens. Also, knowing that gates are unlocked and things aren't chained closed, and those kinds of things make dealing with an emergency much, much easier. The things that the athlete can do is just to know where things are. A lot of times you play in a field and it's a new field that you haven't played on before, or if it's a field that you're familiar with, know where the water is, know where the shelter is, know where the shade is, know where they keep those defibrillators if you need to run and get one. Make sure the field conditions are okay.

If a field is all pockmarked and rotted and has the holes and all kinds of dangerous situations, let somebody know, make sure that gold is stable and not going to fall over those kinds of things. So as an athlete, you have a responsibility to make sure that the conditions are okay for you as well. So hydration, we're going to talk a little bit about hydration. First thing I usually ask you is what is hydration? And most people say, "Well, that's when you have enough water, when you're drinking enough." So then dehydration is the opposite of that when you're not drinking enough. And that's a pretty good definition, but really what we're looking at is dehydration is an excessive loss. It's not just losing a little bit of fluid, it's losing a lot of fluid. And that could be through a variety of different ways. That could be through sweating, through urination, through diarrhea, through vomiting. You can lose those fluids in a variety of different ways.

So most of the times we see it's obviously through sweating, but it's certainly, certainly an issue. There's something called heat illness, which is different than dehydration. Heat illness is a little bit more severe. It's when your exercise has gotten you to a point where you start almost shutting down. And it occurs equally with boys as well as girls, and it is very surprising very often for folks to realize that dehydration occurs indoors, as well as outdoors. A lot of times people assume well, you have to make sure you're hydrated outside because it's so hot outside. But guess what, volleyball players, basketball players, those kinds of sports, absolutely, the athletes get dehydrated as much as they do outside. So just don't think it's a male or female thing, and don't just think it's just indoors or outdoors. It's absolutely both. And good indicator on what they do at the professional level, believe it or not, is they use a spectroscope which takes a look at color measures color.

And they test urine from the athletes to see how much they're hydrated on a regular basis to make sure that their fluid level is up. So it's a serious thing even at the really college level athletics and high end professional level athletics. So make sure you're hydrated and very often, we see if you've been dehydrated, maybe you can think about some of the symptoms that you felt. But certainly on the left hand side of this slide here we see that it's thirst obviously but it's also dry mouth and muscle cramps often are occurring because of not enough fluid intake, tiredness, weakness, dizziness, those are all signs of dehydration. That's your body telling you that you are already behind the eight ball in terms of getting fluids. You are already late in getting fluids if you're feeling that way. I'll tell you what, if you see that down the left hand side we see signs of dehydration on the right hand side signs of heat exhaustion.

Dehydration turns into heat exhaustion very, very, very quickly. I would say if you don't address dehydration within eight to 10 minutes, it's very easily turns into heat exhaustion from that point. And heat exhaustion is a whole nother level of dehydration. You start feeling nauseous and maybe throwing up, you start sweating, actually you stop sweating to a point where you become cool. If you get to a heat exhaustion point where it's very severe, you get cool and your skin is cool and moist and pale as opposed to heavy sweat. You get rapid a weak heart rate. And this is your body actually starting to shut down. So you want to actually when you see your signs of dehydration, you want to immediately, immediately get some fluids in you. Coaches know that fluids should be available on demand and that during the sports, there should be fluid breaks during the activity as well. But bad, bad things happen when heat exhaustion is not addressed.

And it's your body telling you that you're in trouble, you need to do something. And again, if nothing is done in eight to 10 minutes, then we start looking at ambulances and those kinds of situations that need to be called. So there's some environmental concerns, especially living here in Florida. In Florida, we obviously have heat. And during the summer, it's not unusual to have a month of 90 plus degree days, and not only that, but the humidity is very, very high as well typically. So we tend to have kind of the worst case scenario for these hydrations and heat exhaustion kind of situations. Very, very extreme heat, very, very humid. So you need to make sure you dress appropriately and again to know where those safety areas are for shade and fluids and those kinds of things. So when we talk about heat, we talked about heat, we talked about hyperthermia. When we look at cold we look at hypothermia, might have heard that word before.

Hypothermia, most people think that that doesn't occur in Florida but actually we do see hyperthermic situations in Florida. Sometimes in the wintertime, especially with let's say, swim team when the waters actually significantly cold and they're in the water for extended periods of time. We have seen hypothermic situations in Florida. But overall what people tell people was to hydrate, hydrate, hydrate. In fact, when I was a kid a million years ago, they used to tell us just hydrate, keep hydrating, hydrating. And I used to think to myself, well what the heck does that mean? So think to yourself, what does that mean? How much is enough to be drinking? Do you know how much you should be drinking if you're playing sports activities? So think about that for a second, how much should you be consuming water wise when you're playing sports? And I'll tell you what, most people get this answer wrong because it's a lot more fluids than you realize.

Most people say when I ask that question, they say eight glasses of water a day. But in actuality, eight glasses of water a day is good if you are at home, in air conditioning, working on the computer, on a nice normal day. However, when you're playing sports, it's a much different situation and you need to drink much more fluids. You should be drinking fluids before the activity, during the activity and after the activity. So before, during and after. You drink fluids about 30 minutes before because you know your body is going to be sweating and losing a lot of fluids. So you try to prep your body a little bit before. During the activity, about every 20 minutes, you're supposed to be drinking by CDC guidelines, if you're less than 90 pounds, about five ounces of water every 20 minutes. And if you're over 90 pounds, about nine ounces of water every 20 minutes. And it's kind of hard to figure that out, like well how many ounces is each drink? But a gulp of water is about a half an ounce of fluid.

So if you're under 90 pounds, you should be taking about 10 gulps of water every 20 minutes during the activity. And if you're over 90 pounds, it's about 18 to 20 gulps of water every 20 minutes, which is a lot of water, like I said. And then afterwards, you're supposed to drink 20 minutes afterwards for the first hour to get those fluids back if you need them. And most kids when I tell them that it's this much fluid or this much liquid that you need to be taking in they say, "Oh my gosh, I'm going to be going to the bathroom more than playing my sport. It's crazy amount of fluids." But guess what? In Florida, you sweat and you perspire off your skin without you even knowing it. The evaporation rate off of your skin, you don't even realize you're perspiring and you're perspiring and losing fluids without even realizing it. So even though it seems like a lot of fluids, you will go through those fluids without even realizing especially if you're exerting yourself significantly.

The treatment for taking care of heatstroke is now something that is by law and we're very proud of it. It's Zach Martin law. Zach Martin was a kid who actually passed away from heat exhaustion. And we set into place this year actually 2020, we set into place a law that mandated they're at a high school level that they have a cooling tub in place. So what the treatment for heatstroke is, is to cool the person down as soon and as quickly as possible. That means taking off equipment. That means being in shade. That means a tub of ice that you're dumped into, to cool the body down, taking fluids in if possible and immediate transport to get into the hospital for further care if something significant happens. So before we go into concussions, I want to just talk one more thing about fluids. Very often I have people say, what's the best drink? Is Gatorade better than water? Is this better than that?

Most people know that drinking water is their best bet but sometimes it's very convincing to kind of have a Gatorade instead of water. And you think that, well, if I'm spending the money, it's got to be better. And here's my thing with fluids in water versus Gatorade. If you are a college athlete, if you are running a marathon, if you are training for the Olympics, then Gatorade may be an appropriate drink for you, maybe something that would be better for you. But there's a lot of things in Gatorade and those sports drinks that you actually don't need. There's a ton of food coloring, there's sugars, there's salt, there's some things you may need like potassium, and salt and electrolytes and those kinds of things. But at a regular level that we are at now that I know I'm at, I know that I'm suited to have water as a good fluid to drink as opposed to having all the extras in a Gatorade that I'm spending money on.

So really, Gatorade is good for really a professional level athlete. But you really have those minerals and everything else, the electrolytes going through you rather than going to work for you and your system. And you're wasting money if you're spending all that money on Gatorade as opposed to just drinking water. So concussions. One of the first things I ask is what is a concussion to people? And very often, I'll have people say to me, "Well, a concussion is when you get hit in the head." Or somebody will say, "Well, a concussion is when you lose consciousness," which are okay answers, they're not great answers, but we're going to talk about what actually a concussion is. A concussion for lack of a better term is brain injury, to be frank, brain damage. Whoops, let me make sure that this goes over here. Your brain sits in your skull in fluid, and your brain moves inside your skull. And when your brain moves, because it's floating around in this fluid, it will keep moving if you stop suddenly.

So if you suddenly stop, and you're moving quickly, and suddenly are halted dramatically, your brain will keep moving and move to the forward part of your skull, and potentially bruise or damaged part of your brain. And it may go back into the back part of your skull if you flung around very, very hard. So it's hard to imagine, but when a concussion occurs, and it's hard to diagnose when a question a concussion occurs, because all this, of course, is occurring in your skull, inside your head. But the same I want, the point I'd like to try to make is that the same injuries that you receive on the outside of your body actually occur in your brain. So what do I mean by that? Let's say you cut your arm. Well, if you cut your arm, you bleed, right?

So in the brain, that's called a hemorrhage, same thing, just a different word for it. If you bruise your arm gets a big black and blue mark, right? Well guess what? In the brain, brain bruises too, they call that a hematoma. If you have swelling in your arm, after a game or doing something, guess what brain swells up too, brain swelling is called edema. So certainly the same things that happen outside of your body occur in your brain, although you can't see it. And that's when it becomes dangerous. So we want to make sure that you're aware that those same kind of things that occur, occur inside the skull without you even realizing it, which is why it makes it so dangerous. One of the things I like to try to do is kind of talk about some of the myths surrounding concussions because there's a lot of myths. So what's one of them that I've heard very often. Well, you lose consciousness when you have a concussion. That actually is false. You do not have to lose consciousness to have a concussion.

In fact, most concussions occur without any loss of consciousness at all. The athlete you may be walking around dizzy and confused, maybe nauseous, maybe disoriented. However, they are wide awake and walking around. So they don't have to lose consciousness to have a concussion. Next thing I hear all the time is you're more likely to have a concussion during a game rather than a practice because in the game, you're playing really hard, versus playing in practice where you just kind of practicing. So that you're more likely to have a concussion during a game. Well, actually, that's false as well. You are more likely to have a concussion during practices rather than a game for a couple of reasons. One reason being that you practice much more frequently than you actually play the sport in competition. So you're practicing probably two or three or more times, than you actually play in games. So that alone makes your chances of having a concussion more likely.

Also, you're learning techniques during practice that you haven't perfected yet. So because you haven't perfected those techniques yet, you're practicing those techniques during a practice, we may cause an injury, where as in when you're playing a game, hopefully those techniques are honed down to a good skill set, that you're able to not injure yourself. So that's another reason why practices are actually more dangerous for concussions than the games. Another myth, you have to hit your head to have a concussion, true or false? Well, guess what? False, you do not have to hit your head to have a concussion. In fact, at the trauma center, in our emergency departments, very often we see somebody in a car crash who actually hasn't hit their head, but have been flung around the car so violently, that their head whips around and whiplash kind of situations, and their head moves around. And they have those hematomas and edema and hemorrhaging, because of the motion that they received, and not actually having impact with anything.

So you do not need to have hit a head to actually have concussion, but just that violent motion can cause concussions by themselves. One of the myths I've heard of also is, someone has that when you have somebody that has a concussion, or is suspected of having a concussion, that you just can't let them sleep. I think this is based around people thinking that they didn't want people to slip into a coma or something horrible like that, but that's false as well. Right now, the standard procedure is you're allowed to let people rest, but you keep them away periodically. So you will wake somebody every quarter hour every, 15 minutes for the first two hours, and then you wake them up maybe every half hour for the next two hours, and then hourly, as the time progresses. But you are allowed to let them rest periodically, you wake them up only periodically through their recovery.

So you are actually allowed to let them rest, although you check in periodically. One of the things I wanted to mention, which is really interesting, I think, is I asked people all the time before, one of the things I get asked constantly is, "Well, what activity is the most dangerous for concussions?" And I want you to think about that for a second. Which activity do you think is the most dangerous for concussions? And most people say, well, football, obviously that's the most dangerous of concussions. Or somebody will say well hockey, or they'll say, basketball or baseball, or wrestling or something along those lines. And I have to say, "Well, not really." And they go, "What do you mean?" And I say, those are not really true. The answer to that question, which is the most sport, which activities the most dangerous for concussions is really the answer is pretty much it depends. And it sounds kind of like a snarky answer but it depends on your age.

So if you're 8 to 13 years old, that age range, if you look at that chart, the most dangerous activity for a concussion, believe it or not is bicycle riding, cycling. Which is why we have a bicycle helmet law in place because the legislators saw that data and were like, "Holy cow, we need to do something about that. And if we see that many cycling injuries from 8 to 13 year olds, we need to put a helmet law in place." So there is a helmet law. And by law, you're required to wear a helmet up until what age? It's hard when sometimes, sometimes I get 18, sometimes I get somebody saying seven, sometimes I hear somebody saying 21. But the helmet law you are required by law to wear a helmet up to age 16. And frankly, if you value your brain, you will wear a helmet your entire life because it's that dangerous and you can do some significant damage.

So cycling certainly is one of the leading causes of head injury and concussions for younger kids. Now if we look at older kids, you'll see that shift, right? Now, what are we looking at? We're looking at football and basketball and soccer and baseball. Those more organized sports. So what does that mean? Well, you're 14 to 19 years old, you're bigger, you weigh more, you're faster, you're stronger, you're hitting harder. So guess what? Those organized sports, we see some more injuries associated with them. And it's kind of interesting to me because I tend to look at soccer because I think the soccer injuries are kind of relevant for both males and females. And if they place the sport equally, and I'd like to see where, it's interesting where boys get hurt, and versus where girls get hurt, especially for soccer.

So if you look at this chart here, or this graph, or graphic, excuse me, you can see that boys kind of get hurt with soccer at least in their hips, and their upper thighs, their ankles, their lower legs, those kind of things. If you look at girls, girls with soccer, huge, huge issue in the head in the face area. Head, neck, face. They also have injuries in the upper legs, and the ankles as well, but much different in terms of the head and neck. And down below in that graphic, you'll see that football is the most dangerous per number of players, right? Because every football play is contact and a collision. So you're going to see some injuries there because of just the nature of the sport. But right behind football, girls soccer. Girls soccer is a very, very challenging and aggressive game.

And if you've ever been to us, I challenge you to dare to say that a girl's soccer match is not as aggressive as boys. It's actually more aggressive times and actually really intense playing. So don't ever think that they're girls and they're not going to have injuries or have concussions or anything because they're right behind football in terms of having issues for their sports. And there's a reason for that, and the reason isn't really that their concussions... I'll go into the reason in a second, but they have 68% more often they have concussions than boys when they're playing soccer. And it took them longer to recover from the symptoms than the boys.

And why is that? Well, physiology meaning that the structure of the body, girls tend to be longer and leaner and their necks, they also have 26% less mass in their head and neck areas than boys do. Boys tend to have this meaty neck and meaty shoulder area that acts as a shock absorber where girls necessarily don't have that. So because they're less developed than boys, they are not able to absorb the impact as well as boys are. And sometimes they have injuries. And again, they're playing hard and which is why they're having the injuries they're having. So what I see very often is that people say, "Well, they're hitting a ball in soccer, that's why they have concussions." Not really, hitting a ball properly is not going to give you a concussion really, but what we see most often happening is that concussions occur, especially in girls soccer, head to head contact, and head to ground impact.

So those are the areas that we have more concern with. Proper technique with heading a ball is going to do well to prevent any injury. Some of the things I wanted to go off to, what actually is law, this is fairly recently, all these things. So before these laws weren't necessarily in place, and now they're really really regimented in place. So one of the first things that's Florida law is that you have to be aware legally from the coaches, the officials, the parents, the athletes themselves, have to be aware that there's a risk and a certain risk of nature to sports, which is fine. I mean, there's more benefits that we said than risks. But you have to be aware that there's certain risks to sports. Also, you have to sign a consent form saying I understand these risks. Same thing with the parents, everybody has to be aware of that, you know what? Things can happen, but you know what? The good things outweigh the bad things. Also, there must be if you are, and this is, again, fairly new.

If you have a head injury or suspected of having some kind of head injury, it's by law that you have to be immediately removed from the field, immediately removed. And I'll tell you what, like I said earlier, a million years ago, when I was an athlete, you got hurt on a field, you were taken off. Coach might have said something like, "Oh, you got your [inaudible 00:34:29] wrong. Come on, sit it out for a few minutes and we'll get you back in. Or oh, wait a couple plays, and we'll put you back in, you just got the wind knocked out of you," or that kind of thing. And I'll tell you what, it can be significantly a problem. You go back in with a concussion. It's a big, big deal now. So it's by law that you have to be removed and not only removed, but get written clearance by a physician before you resume your athletic activities.

In fact, also a law, the physician is allowed to hand off some of those responsibilities if you feel there's a concern to neuro psychologist or psychologist, to test your reaction time, to test your memory and language, to test your motor coordination to make sure that you are back to baseline before you get back on the field before you participate back into academics. What the typical symptoms are with concussions, most likely in the very bottom of that chart there you see most often it's headaches and dizziness, maybe some confusion, very rarely do we see visual problems and those kinds of things. More often we see the headaches and dizziness kind of situation. But the course of treatment for and what an athlete feels, excuse me, is a kid will never approach a coach or a parent and say I have a concussion, please take me out of the game. What a kid will say is, I don't feel right, something is wrong.

And sometimes there'll be nausea, sometimes they'll say that they're sensitive to light and the lights are bothering them, or they have a hard time concentrating or there's confusion and concentration and not sure their position or what the play is. So you'll see athletes that feel that way. But the athletes themselves may report that they see, you might see them looking a little stunned and confused. Even if they're not saying anything, they might be moving clumsily. You might see a personality change, very aggressive or very passive, as opposed to their normal self. They might come and not be sure the game with the score or what the last thing that happened before their hit. So those are the things that as a parent or a coach, you might see. But again, a kid themselves will not say I have a concussion.

What we're trying to do, we're trying to avoid, and it seems like a lot of work to try to avoid this. But it's really, really important. We're trying to avoid what something called second impact syndrome. And second impact syndrome is when you say get a concussion, where you have let's say edema swelling in the brain. And the athlete doesn't say anything or the athlete says something and the folks ignore it. And that brain is swollen. And they go back into the game with a swollen brain and get another concussion on top of that first concussion. So they have a second impact syndrome, which means that, frankly, a lot of the symptoms that we mentioned, that were temporary, like the confusion, a headache, nausea, dizziness, memory issues, those things that are temporary, actually become permanent. So we want to make sure that that never occurs.

Most kids recover from a concussion within three to five days. And we'll go over that in a second. But when you have a concussion, and go back into the game, and get a second concussion, bad, bad things happen. So the regular return to play paradigm, or schedule, very much looks like this. If you have a concussion, again, three to five days most concussions resolve themselves. But what has to happen is you have to be, there's a time, the cure for a concussion actually is rest and calm. And you go from having what's called a hot brain, which is swollen and maybe bruised to having a cool brain which is calm and the swelling has decreased and things. The way to make that happen is you have to be completely symptom free for one week. What does that mean? That means you are sequestered in your bedroom more likely than anywhere else with the lights out, no television, no video games, no phone, no stimulation for the brain for a full week, make sure that there's no symptoms like nausea, headache, dizziness.

After that, there's no symptoms, you get another week with maybe some easy exertion the following week. And again, no symptoms have to be included in that. So no headaches, no dizziness, no vomiting, anything when you're having easy exertion, then you can gradually return after that second week back to play if you have major concussion. Certainly if something happens in the middle of that, like if you start to see some symptoms with some easy exertion, guess what? We go back to step one, and we go a week without any exertion and make sure that the brain is calmed and cooled. So that's how it primarily occurs. But again, usually within three to five days, things resolve themselves for majority of concussions. Younger children recover slower than older kids and adults. So you have to be aware of that as well.

And again, there's medical clearance that's necessary before you return to academics or to play. Very often people forget that the coach or an excuse me, the referee, referee is crucial in terms of controlling the aggressiveness of the game as I mentioned earlier. Very often the data shows that right after excuse me a major injury or concussion usually occurs right before a referee will throw a card or a penalty. So we need to make sure that the referees are very, very careful to watch the aggressiveness of the game, and to call kids on being overly aggressive. Again, another prevention tip for concussion is just proper technique. Proper technique will go a long way in preventing any kind of concussions as well as proper training. So muscle strengthening in those areas that we want to strengthen and make sure that we have enough muscle to absorb some shock, it definitely helps. And then we're going to talk finally about overuse injuries.

And overuse injuries are very much as it sounds, it's overuse of a certain muscle group that you have an injury with. So what does that mean? Well, it means that we tend to see these kinds of injuries much more frequently than something like a concussion. So what are these kinds of injuries? These are kind of sprains and contusions, fractures, dislocations, much more frequent than those other issues that we were talking about with concussion. And the severity of these things increase with the child's age. Very often, as we get older, we start again, moving faster, hitting harder, putting our body under a little bit more strain, and then we have these kinds of bigger issues. We actually call these overuse injuries, micro traumas. And those very often associated with an intense level of activity.

Very, very common names for some of these things are swimmers shoulders or little league shoulder or stress fractures, a little league elbow or tennis elbow, very, very, these are all stress overuse injuries. And a lot of times, what ends up happening is that this occurs because we are not giving ourselves a chance to rest. One of the things I always ask kids is does muscle build when you're working out and lifting weights, or when you're resting? And the answer is actually, when you're lifting weights and working out hard, you're breaking down muscle, your muscle builds when you're resting, which is why we work out very often on a Monday, Wednesday, Friday, or on certain muscle groups and Tuesday, Thursday on other muscle groups, because you need to give your body a chance to rest and build instead of breakdown, breakdown, breakdown or that breakdown, breakdown, breakdown, lifting weights breakdown, breakdown.

If you do not give it a chance to rest and build, you're going to eventually hurt yourself. Also, kids have what are called growth plates. And I don't know if you can see my little arrow here but as you're growing, there's hard bone and then there's cartilage that's still growing. And you have this plate in between a space that you're continuing to grow. When your muscles are being stretched to the limit and pulling you tend to widen this gap here, this growth plate. And this gap at tends to end it tends to be a very, very painful experience. When you start pulling apart the growth plate and the bone from the cartilage. So please make sure that you're aware that even though you want to train like an adult, you are still young athlete. And you need to not be training like an adult, because you will sustain some of these injuries. Why do we see this kind of stuff happening so often? Well, kids today play sports differently than when I was a kid.

When I was a kid a million years ago, we played one sport and then the season changed and we played another sport. And then that season changed and we're playing a different sport in different position. Now, kids play one sport, they tend to play one sport all year. Not only that, they play one position in that one sport all year. And not only that, they play multiple leagues within that season in that one position all year. And because of that, they tend to have more of these overuse injuries of specific muscle groups, because they just are overusing those certain muscles. If there is an injury, they need to see the physician immediately. But hopefully, athletic trainers and things, and nurses on the field are in place to kind of see when things start to get a little bit uncomfortable for an athlete to kind of bring them back to trying to relieve some of these issues, so that they're not working out in the same way, all the time. One of the ways to help and prevent overuse injuries are very simple.

It can't be overemphasized, warming up and stretching, huge, huge to prevent overuse injuries. You forget to warm up, or you forget to cool down, very often, injuries will occur. Stretching, proper stretching, is a great way to get your body ready to do your exercises. But forgetting those things, you very often have an injury. The way to avoid overuse, cross train. We don't tell kids, "Oh, just sit out a whole season and don't do anything, but do something different. If you're a runner, maybe swim. If you're a swimmer, maybe bicycle ride. If you're lifting weights, maybe do something else, but don't use the same muscle groups over and over." And also this will help prevent burnout as well, you won't get bored and tired of playing sport.

I just like to briefly talk about safety gear, because I see this as an issue very often. Very often athletes try to get away with smaller gear than what they have. And what happens is, is that you're not protecting the area that you want to protect. So very often, like a soccer player will wear very small shin guards because they can feel like they moving quicker that they can move faster. Same thing with football players, when they have shoulder pads and those kinds of things. They tend to do smaller shoulder pads or smaller gear so that they can move quicker. And what ends up happening is they end up hurting themselves, because the gear is not covering where they need to cover. You also need to make sure that that gear is in good condition. Something too small will actually constrict blood flow, and cause potentially to constrict breathing and those kinds of things, which can be obviously devastating if it's an issue when you're exerting yourself.

So make sure your equipment is the appropriate size, and that you're using it and that it's covering the areas that you need to protect. This is a big thing for Safe Kids Southwest Florida and it's a very interesting topic. 70% of kids participating in sports drop out by age 13. Can anybody tell me or think about why that might be? Why do 70% of kids participating in sports drop out by age 13? And by dropping out, they lose all the benefits of the sports that they provide. Well, they surveyed these kids, and they asked them and a lot of times I'll hear, "Well, the kid couldn't cut it and they dropped out." Or that the kid was not good at the sport and that's why they dropped out, or something along those lines. When they surveyed the kids, 70% of those kids dropped out by age 13 because they just were not having fun anymore. They weren't enjoying it. It wasn't fun.

And because it wasn't fun now they're losing all the benefits that the sports provide. So I tell parents to kind of remember to let the kids be kids. If the sport is not fun, it's not going to be enjoyable, and it's not going to be something they're going to want to continue with. So keep sports being fun. Don't let it be hyper competitive. Obviously, we want you to do well and we want you to perform well and perform your best, but you've got to remember that it's still a game and it's supposed to be fun. So parents, I try to remind them to make sure they get that pre-participation physical exam annually. Always stay hydrated.

If you see signs of concussion or injury or overuse injuries, please get them checked out by a doctor as soon as possible and do not let them back until they're cleared. Try to get an idea of how to prevent injuries. If you need to CPR training, that's awesome. Learn how to use an AED. But parents need to be setting realistic goals for their kids. They shouldn't be living vicariously through their kids through their own athletic abilities or try to force a kid to do something they're not wanting to do. A kid who's a good athlete will want to practice and want to do things, you shouldn't have to push them. And the parents job is not solely to make sure her kids do the best. The first job of a parent really is to make sure they're safe, and then their second job really is to encourage them to do their best.

 I want to thank you for listening to me for this hopefully interesting talk. Keep those things in mind. Again, the goal of this presentation is to keep people playing hard for a lifetime. And the way to play hard for a lifetime is to play safely. Thank you very much. I hope you enjoyed this. If you have any questions, please don't hesitate to call the Lee Health Trauma Center for any other questions or concerns. And hopefully I'll be able to sit in front of you and talk with you in the future. But hopefully this video, interim process, virtual talk is helpful to everybody. Thank you and have a great day.