SURF: A Unified Surfing Competition Medical Reference Form

The Authors of this manuscript propose a standardized medical record to be used at surfing contests with the dual purposes of documenting medical information as well as for future research endeavors. Currently, medical data at surfing contests is gathered in somewhat haphazard fashion, creating a sub-optimal medical record and making the data very difficult to analyze for research purposes. The SURF form will allow for the uniform collection of surfing-related injury data at surfing contests worldwide which can easily be de-identified and compiled into a large database used to evaluate mechanisms of injury and risk prevention strategies.

Surf scientists rejoice!

From the ₁Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, Mississippi; ₂Department of Internal Medicine, University of Hawaii, Honolulu, Hawaii, and Waves of Health; and the ₃Kaena Kai Clinic, Haleiwa, Hawaii 

Corresponding author
Brittain Cross, DO
University of Mississippi Medical Center,
Department of Emergency Medicine,
2500 N. State Street, Jackson, MS 39216, USA.
E-mail: bcross89@yahoo.com

Abstract

The goal of this study was to propose a uniform system for recording medical care while simultaneously collecting equivalent data at multiple surfing competition events that could be used for future compilation and comparison. The authors reviewed data of surfing injuries and proposed risk factors from prior surfing research and combined the information with consensus author opinion to create a simple form for recording surfing injuries and potential risk factors. The data could then be used as a form of medical documentation as well as for potential future research studies.

Introduction

Surfing is one of the oldest sports practiced today. It is believed to have its origins in Polynesia or Micronesia with current participation levels reported to exceed 18 million surfers worldwide [1]. There are amateur and professional events held every year throughout the world. These events are usually staffed with trained medical providers and provide a great opportunity for collecting data related to surfing injuries. To date, there is no commonly used universal medical form for documenting surfing injuries and the potential risk factors that may have led to these injuries. The goal of this study was to propose a uniform system for recording medical care while simultaneously collecting equivalent data at multiple surfing events that could be used for future compilation and comparison.

Methods and Materials

The Surfing Unified Reference Form (SURF) was created by analyzing material from various surfing research data and combining this data with the consensus opinion of the authors. Data was collected from a review of prior published surfing injury studies (Table 1). PubMed search for surfing injuries was used with 19 articles evaluated, of which 8 articles were chosen based on their inclusion of common surfing injuries. Multiple surfing organizations were contacted, including the Association of Surfing Professionals, Eastern Surfing Association, Western Surfing Association, International Surfing Association, and Florida Surfing Association. There were limited responses but with no report of current use or knowledge of a common medical reference form used during competition. Author opinion was developed over years of medical event coverage at professional surfing events around the world. Following analysis of this information, potential risk factors for surfing-based injuries were compiled to form the SURF. This simple, easy to understand form was designed to be used at any surfing competition with the goal of high inter-rater reliability.

Results

After reviewing multiple articles reporting surfing injury data, a list of common injuries and possible mechanism were obtained. The most commonly reported injuries were lacerations, contusions, sprains/strains, fractures, tympanic membrane rupture, and marine envenomation, including jellyfish stings. The most common suspected mechanisms involved contact with a surfboard and/or the sea floor. Wave height was also speculated to be a factor in surfing injuries.

Upon further discussion, a list of potentially useful questions were compiled and placed into a single page table style format (Table 2). The justification for each heading is discussed below:

Pro/Amateur event: Studies have proposed a difference in the amount and type of injuries when comparing novice to expert surfers [1]. Some state that expert surfers have more injuries due to a higher level of risk taking while possibly competing in generally more dangerous surfing conditions [1]. On the contrary, it might seem reasonable to argue that amateur events are more dangerous because the surfers are less skilled. While comparison of professional to amateur events does not directly indicate skill level, it is believed that this differentiation might increase inter-rater reliability while decreasing the opportunity for human error by eliminating the individual surfer’s subjective skill rating.

Wave face size: Studies suggest an increased risk of injury with increased wave height, specifically making a distinction between greater than or less than head high [2]. Wave height is measured from wave peak to trough and should include the unit of measurement. The term “wave face height” was chosen specifically over the term “wave height” in an attempt to prevent confusion with the Hawaiian scaling system or any other system that may measure wave size from behind the wave.

Bottom Type: Bottom type has also been indicated as a possible predictor for increasing surfing injury risk. Hard bottoms, such as reefs, are suspected to predispose surfers to a higher number of injuries when compared to softer bottom types, such as sand [2]. Understandably, this will be somewhat subjective since surfing breaks will often contain a combination of different ocean floors, such as reef pockets surrounded by sand. For this reason, and based on the idea that hard ocean floors likely play an important role in surfing injuries, an arbitrary percentage of 25% or greater of reef within a surf break will be considered a hard bottom. Surfers who report injuries based on contact with a soft bottom, such as sand, while surfing in a previously determined hard bottom surf break, or vice versa, may have this noted in their mechanism of injury or comments section, and this may be adjusted later during contest data compilation.

Air/Water Temperature: Air and water temperature are included to look for a correlation between temperature and surfing injuries. Cold weather can increase risk of injury during athletics when heat loss exceeds heat production [9]. Likewise, hot weather can be dangerous in water sports, as noted by reports of exertional heat illness among swimmers in the FINA World Aquatic Championships in 2009 [10]. Ideally, air and water temperature would both be recorded along with the time of day and unit of the measurement.

Conditions: The actual surfing conditions will be subjective for a particular surf break but is generally thought to include factors such as wind speed and direction, tide, and current weather (sun, rain, etc.). Even if not known specifically by the medical provider, this information can usually be obtained from the contest director or supervisor who knows the local surf break well. The terms good, fair, or poor have been chosen to promote simplicity while increasing the likelihood of obtaining this information by the medical provider.

Comments: A comments section is provided for any other information felt to be important by the medical provider for the particular contest.

Name: Patient name is included for several reasons. The SURF was created as a simple form for documenting medical care at a surfing competition. Though a surfer’s name is not necessarily required for research purposes, it is important for medical documentation. The form may be used as a simple reference should any question arise later regarding medical care. This limited data may be all that is required for mild injuries while more complex presentations may require more in-depth treatment plans, which can be recorded on additional sheets and easily attached to the SURF.

Names may also retrospectively allow the determination of individual patient’s risk factors. An example of this type of analysis might include a summation of total time in the water prior to a particular injury by extrapolating the number of heats and heat length of the patient during the event.

Age: Age is an important aspect of the SURF with respects to injury risk, especially when compared to other sports. Nathanson et al [1] found an increasing risk for injury with increasing age, with the highest risk occurring at ages 40 and older. Age is an objective measurement that can be easily compared across a variety of surfing competitions and may guide recommendations for specific protective equipment and training recommendations. It can also be used to compare the relative safety of surfing to other common sporting activities within a similar age group.

Male/Female: Gender was included for both medical documentation and future research purposes. One study showed no difference in the risk for injury when comparing men and women [1]. Additional evidence regarding this relationship might further confirm this finding of gender as a non-factor for surfing injury risk while contradictory data might suggest the need for gender specific protective gear or training.

Currently Competing: Providing medical care at a surfing event often involves more than treating competing surfers. By-standers, fans, and other ocean goers often present for routine medical care, such as treatment for minor abrasions or basic bumps and bruises. The decision to treat these patients is left to the discretion of the medical provider. However, the SURF is designed as a versatile form that can be used for medical care at surfing events, regardless of the presenting patient. Providing a “yes or no” response concerning whether the patient is currently competing allows the provider to delineate competitive surfing data while also allowing the consistent documentation of all patient care.

Injuries: This column is intended to include all injuries for which the patient is presenting for care. This phrasing allows the provider to record all pertinent injuries for which the patient presents, regardless of chronicity.

Acute vs. Chronic: The intent of this phrasing is to distinguish between pertinent acute injuries and stable sub-acute or chronic injuries. An injury from competition would obviously include newly presenting conditions but would also include acute worsening of existing injuries. An example of the latter scenario might be an individual with chronic low back pain who had acute worsening during competition. A current injury, such as a current ankle sprain, which occurred prior to the event and did not worsen during competition, would not be considered a new injury that occurred from current competition. This delineation will improve the accuracy of future data concerning the true occurrence rate of competitive surfing injuries. In the event of multiple injuries, this category may require the provider to delineate which injuries are new and which injuries are sub-acute or chronic.

Mechanism of Injury: The mechanism of injury should be recorded as described by the patient and/or witnesses. This may include physical maneuvers, such as paddling or attempted board maneuvering while riding. This category may also include natural mechanisms including wave knock down or hold down as well as injuries from marine animals. Injury from one’s own surfboard or the board of another surfer may be listed here as well but should also be further delineated in the next field. Understandably, this information may not be completely known but should be recorded if possible in order to provide the potential for future analysis of previously unknown injury risks.

Area of Board Causing Injury: Studies have shown that over half of surfing injuries are related to contact with the surfboard [1]. In a study from the American Journal of Emergency medicine, Nathanson et al [1] reported 67% of acute surfing injuries resulted from direct trauma from a surfboard, including injuries resulting from contact with the nose, deck, tail, rail, fins, and leash. For this reason, more specific data is sought. Therefore, in the event of a surfboard-mediated injury, the area of the board causing injury should be recorded if possible. If the surfboard was not involved in the injury mechanism then the provider may simply place N/A to indicate this field is not applicable to this particular patient.

Protective Gear: Protective gear is another field of increasing interest as the push to increase sporting safety continues. Protective gear is intermittently used throughout surfing at this time. Helmets have been recommended to potentially reduce the risk of head lacerations, concussions, and tympanic membrane perforation [1]. In one study of 646 surfers, only 12 reported routine use of headgear [11]. Other protective gear includes surfer-worn protection including rash guard clothing, wetsuits, braces, or flotation devices.

This category should include board safety devices, such as a softer nose guard over the pointy tip of the board. The ideal protective gear would keep surfers from the medical station in the first place, and it would be difficult to determine how many injuries were prevented from protective equipment as this form is designed to record actual and not prevented injuries.

However, the use of this equipment, when combined and examined over a larger scale, could show failures of protective gear. The data may also allow investigators to postulate potentially prevented injuries from the use of this equipment based on the mechanism of injury. An example of this might include the finding of facial bruising without lacerations from contact with a soft rubber fin instead of a predicted laceration if a hard fin had been used.

Supplies Used: This column was added in an attempt to gather data concerning the types of medical supplies and equipment used at various surfing events. A survey of team physicians was previously conducted documenting the most commonly packed and used medical supplies within a sideline medical bag [12]. Further information regarding commonly used medical supplies at surfing competitions would potentially assist in the creation of sport-specific medical supply recommendations for surfing events.

Treatment/Comments: The treatment and comments section provides the intended location for documentation of the medical decision making and treatment of the individual patients. The provider is encouraged to be as specific as possible within each event’s medical capability to provide accurate diagnoses. Injuries necessitating hospital care are particularly important to document as they likely indicate a more severe injury. Additional comments felt by the provider to be pertinent to the patient’s condition should also be included in this section. If extensive documentation is required, it can be placed on a separate form and attached.

Discussion

The SURF documentation form was developed to assist on-scene medical providers in documenting medical care while also providing a template to obtain useful data for future surfing-based research studies. While the authors believe the design of this form to be useful in compiling the pertinent surfing competition medical data, there are limitations to the form.

To be effective, a documentation form should be easy to use. The SURF was designed to include the most potentially pertinent information that could be quickly and easily obtained by the provider without becoming burdensome. However, we recognize that some providers may feel the form is overloaded with less important information while others may desire additional aspects for study.

Questions regarding the use of recreational drugs or alcohol were excluded in this form. This was due to the belief that athletes would not, for the most part, intentionally consume substances to the point where their skill might be negatively affected in a competition environment.

Information such as heat length and the number of heats in which a surfer competes are potentially useful in the determination of individual risk factors. However, this information can easily be obtained from competition records during future data compilation. Therefore, these factors were not included in the SURF. This or any other information deemed important for a particular event may be easily recorded by the provider in the comments section in either the event or individual comment sections.

Conclusion

Surfing is an ancient but steadily growing sport involving surfers of all ages, both male and female. As competition surfing continues to grow, the need for more accurate injury documentation increases as well. The SURF form provides a simple, easy method to enhance data collection in the hope of stemming increasingly accurate research in the future while also improving the documentation of all patient care at surfing competitions around the world.

Table 2. SURF

References

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