Athletic trainers and EMS collaboration is best for injured athletes

By Brian Potter

Every year in the United States approximately 1.35 million sports injuries are treated in hospital emergency departments [1]. While typically only a small percentage of sports injuries are life threatening, these statistics show there is a great likelihood EMS providers will be called upon at some point to treat an injured athlete.

When EMS is called to the scene of a sports injury, providers will often be interacting and collaborating with athletic trainers. Athletic trainers are health care professionals who collaborate with physicians to provide preventative services, emergency care, clinical diagnosis, therapeutic intervention and rehabilitation of injuries and medical conditions [2].

While both athletic trainers and EMS providers have different skill sets and areas of expertise, the collaboration between the two professions allows injured/ill athletes to receive the best possible emergency care.

Consider the following scenario:

You are 911 dispatched to respond to the college football practice field for an unresponsive patient. Once en route, dispatch advises you are responding for an unresponsive 19-year-old male football player involved in a helmet-to-helmet collision. Upon arrival you find the patient still on the field with members of the athletic training staff in the process of providing spinal motion restriction onto a long back board. The player’s equipment remains in place; however, the face mask has been removed from the helmet prior to your arrival. The head athletic trainer provides a brief size up indicating the patient was involved in a helmet-to-helmet collision, dropping to the field limp immediately following. The patient was unresponsive to all stimuli for approximately one minute upon the athletic trainer’s arrival at their side, and upon regaining responsiveness complained of pain on palpation of the cervical spinous processes. On initial assessment you find the patient responsive, with amnesia to the preceding trauma. The patient’s airway is patent, respirations are normal, and carotid and radial pulses are intact. There are no obvious injuries found on trauma exam. Working with the athletic trainers, you complete spinal motion restriction and initiate transport. En route to the emergency department you obtain vital signs which are within normal limits, initiate IV access, complete serial neuro checks, and notify the ED of your pending arrival with a trauma.

In this scenario, many aspects of the emergency patient care provided are within the domains of both athletic trainers and EMS providers. Both professionals receive education and training necessary to initially assess and package the patient for transport. Athletic trainers possess a thorough understanding of athletic equipment as well as having the skills necessary to appropriately and safety remove equipment as needed and in this case the face mask was removed to allow access to the airway should the patient have required further airway management.

The athletic trainer also has the distinct advantage of often being present at the time of injury and observing the mechanism of injury. In the scenario, the athletic trainer provided very important information to EMS regarding the patient’s injury mechanism, mental status, and initial physical exam findings. The EMS provider possesses the knowledge and skills in packaging and transporting the injured athlete, as well as regular experience managing trauma patients. This includes a thorough knowledge of the trauma system and making a decision as to the most appropriate destination of transport; nearest hospital vs. a higher level trauma center. Paramedics have a more advanced skill set in emergency treatment, allowing for more definitive airway management, establishment of an IV, fluid administration, and medication delivery.

Put differences aside

Fortunately, the scenario discussed is one in which EMS and athletic training interacted seamlessly, positively, and professionally to provide quality patient care during a sports emergency. Unfortunately, there are many cases of emergencies in athletics where the interaction between EMS and athletic trainers hasn’t gone so well, at times even leading to arguments on scene. Several reasons for these negative interactions have been previously proposed and include [3]:

• The territorial nature of both athletic trainers and EMS providers.
• Potential differences in protocols for certain situations such as helmet removal and spinal injury assessment.
• A lack of understanding of each other’s profession and skill set.

Arguing over who is in charge or protocol differences, while standing over a severely injured athlete, is far from ideal. This can be avoided with preplanning between EMS and athletic trainers [3, 4]:

• Joint participation in training exercises (see photo).
• The development and sharing of emergency action plans for athletic venues.
• Formal meetings between athletic trainers and EMS providers.
• Informal discussions (as each profession has opportunities to encounter the other) between athletic trainers and EMS providers.

Develop and follow an emergency action plan

An emergency action plan (EAP) in athletics is a written document that provides a set of guidelines for personnel involved in athletic emergency response. Much like the emergency operations plans utilized in emergency management, the EAP should take into account all possible worst-case scenarios in sports [5]. Essentially, the EAP helps get the right people and equipment, in the right place, at the right time.

Multiple professional organizations have called for the use of EAPs, including the National Athletic Trainer’s Association (NATA), the National Collegiate Athletic Association (NCAA), and the National Federation of State High School Associations. The EAP should include the following [5, 6, 7, 8]:

• Defining emergency personnel potentially involved in response.
• Discussion of emergency communications such as how necessary personnel will be summoned or dispatched.
• Emergency equipment (AED, spine board, trauma kit, airway supplies) potentially needed, as well as the location of such equipment. A plan for skill maintenance in using equipment, ensuring equipment works, and ensuring supplies are not expired should be included.
• Patient transportation, including access and egress routes, aeromedical landing zones, and location of trauma or other specialty care facilities.
• Venue-specific information for every competition. For example, a high school or college may have a practice gym, a main gym used for competition, as well as an indoor pool all housed in the same building. Describe the best access points for each of those venues to minimize response times.
• Directions to each venue, the emergency equipment present at each venue during practices or events, any gates or doors that may need unlocked, and other special considerations for responders.
• Documentation plan, including patient care, after-action reviews, personnel training on emergency equipment and equipment maintenance.

The EAP needs a section on coordinated development, revision, approval and implementation from between athletic trainers, physicians, EMS, fire, security, law enforcement, and others potentially involved in response. Once finalized, the EAP should be tested with training exercises to allow athletic trainers and EMS providers to interact in a simulated setting before a real incident. Evaluation of the training exercise often leads to revisions within the EAP making it more appropriate to each jurisdiction.

Take a pre-event medical time out

One of the best ways in which EMS providers and athletic trainers can foster additional collaboration is through conducting a medical time out prior to any sporting event. The medical time out concept was introduced in 2012 by the NATA and is based off of the medical model of operating rooms conducting a surgical time out before a procedure to ensure correct patient, procedure and body site [9].

The NATA initiative calls for all members of the athletic emergency response team to meet, ensuring everyone is on the same page before a potentially life-threatening injury or illness occurs. In addition to reviewing the venue specific EAP, the medical time out should also include discussion of the following [9]:

• Role and location of each athletic health care provider present.
• Communications plan, method, devices and primary and secondary means of communicating.
• Location of an ambulance, if present. Is that ambulance dedicated to the event or a duty crew standing by? What are the access/egress routes for that ambulance or for an incoming ambulance to use if called?
• Where to transport if an emergency occurs? Where are specialty transport centers located? If aeromedical is needed where is the closest landing zone?
• What emergency equipment is on site? Where is it located? Has the equipment been checked to ensure it is working? Who will retrieve the equipment?
• Any issues such as construction, crowds, or weather that may alter the previously written EAP?

When an emergency occurs in athletics, the response by athletic trainers and EMS providers must be coordinated and collaborative. Building relationships, utilizing EAPs, as well as the concept of the medical time out prior to events will help achieve this goal and lead to the highest quality of emergency care.

References

1. 1.35 Million Children Seen in Emergency Rooms for Sports Related Injuries. Available at: http://www.safekids.org/press-release/135-million-children-seen- emergency-rooms-sports-related-injuries. Accessed January 27, 2015.
2. Athletic Training. Available at: http://www.nata.org/Athletic-Training. Accessed January 27, 2015.
3. Potter, B. Developing professional relationships with emergency medical services providers. Athletic Therapy Today, 2006; 11(3): 46-47.
4. Potter, B., Martin, R.D. Testing the emergency action plan in athletics. Athletic Therapy Today, 2009; 14(6): 29-32.
5. Anderson, J., Courson, R., Kleiner, D., McLoda, T. (2002). National Athletic Trainers’ Association position statement: Emergency planning in athletics. Journal of Athletic Training, 37(1):99-104.
6. Casa, D., et al. (2012). National Athletic Trainers’ Association position statement: Preventing sudden death in sports. Journal of Athletic Training, 47(1):96-118.
7. 2014-2015 NCAA sports medicine handbook. Available at: http://www. ncaapublications.com/p-4374-2014-15-ncaa-sports-medicine-handbook.aspx. Accessed January 28, 2015.
8. National Federation of State High School Associations Sports Medicine Handbook
9. National Athletic Trainers’ Association Official Statement on Athletic Healthcare Provider “Time Outs” Before Athletic Events. Available at: http://www.nata.org/ official-statements. Accessed January 27, 2015.

About the author

Brian Potter, MS, ATC, EMT, OTC is an athletic trainer with Tygart Valley Orthopedics and Sports Medicine in Elkins, West Virginia. Brian has sports medicine experience in the high school, college, clinical and physician office settings. He also has over 15 years of experience in emergency medical services, currently serving as the squad training officer with Upshur County EMS. Brian is a West Virginia EMS instructor, has previously served as an adjunct faculty at West Virginia Wesleyan College, and has published and presented multiple times on topics related to sports emergency care.