Improving Prehospital Care of Athletes

There are many athletic events that EMS may be standing by or called to that traverse the contact and collision spectrums. High school football games are perhaps the most high profile events that EMS may be called on to provide patient care. Any care provided during these events will be seen by a huge number of people. The perception by spectators of high quality care or poor quality care can have negative or positive repercussions for an EMS agency. Even more important is that the care provided by EMS can have major implications for the injured student athlete. The potential for a spinal injury is small but the effects of such an injury can be catastrophic. There are approximately 12,000 spinal cord injuries per year in the US with more than nine percent coming from athletic events. Given that many fire and EMS agencies are at or respond to these types of emergencies, we just wanted to give folks some insight as to how care is evolving in relation to athletic spinal injuries. These injuries and the care given will take place in front of thousands of spectators, with many different types of providers’ presents, and in a chaotic environment. For these reasons it’s very important for EMS to educate itself about how to provide the care and it’s important for EMS to participate in multidisciplinary planning prior to these events image

Evidence based medicine has shown that the continued use of a spine board to transport the patient can be detrimental to their well being. In fact, many EMS agencies are changing their protocols to reflect this. The NCCEP EMS committee has a spinal injury protocol and the use of the backboard is returning to its original intended use of a “transportation device” not an immobilization device. Many EMS providers are unaware of nationally recognized documents that exist that helps guide both EMS and athletic trainers in spinal injury management. The main document that athletic trainers base their practice on is “The Prehospital Care of the Spine Injured Athlete,” was first published in 1998; and has since been updated 2015 and 2016. This document as well as other sports medicine documents still encourages the use of backboards for injured athletes. This difference in practice regarding backboards could potentially cause issues if prior planning and discussions do not take place between athletic trainers and EMS.

One basic assumption comes to light quickly at these events: EMS providers are skilled in injury situations with potential spinal injury. Athletic trainers and school staff are skilled in the knowledge of the gear worn by the athletes and know the individual players. Unfortunately the two professions may be at odds over certain caveats of injury management and it is imperative that trends and techniques be discussed and reviewed prior to games or practices.

For simplicity’s sake, there are several educational points that exist for both EMS agencies and the school or recreation league staff in regard to medical care and a quick summary of these follow.

Educational Points

  • Evidence based medicine shows no improvement with leaving any person — including athletes — on a backboard for transport to hospital. Now is the time to entertain utilization of other devices such as scoop stretchers to make it easier to remove the device once the athlete reaches the ambulance cot.
  • Athletic trainers and equipment managers are the experts in the protective equipment worn by athletes. No matter how much we train, EMS will never know all the ins and outs of athletic equipment. Use your local resources to improve your knowledge base and work with them during these situations.
  • Athletic programs — recreation league and school based — should have an emergency action plan (EAP) developed in conjunction with EMS. EAPs are required by general statute for all North Carolina public high schools. As part of that plan, a thorough discussion about use of backboards per local EMS system plan should occur. EAP drills should occur at a minimum annually at the start of football season, with documentation kept by the athletic programs. Those EMS providers rendering care at athletic events are highly encouraged to have specialty training to handle such events, as these are not the normal “run of the mill” calls we often see. EAP drills should review game response and practice field response, as pre-deployed resources may not be present
  • “Time out” meetings should occur between the athletic program staff and EMS before the game to review equipment and procedures — if EMS on site. Spinal equipment, face mask removal equipment, and a system for notification for EMS to come to the field — suggested “raised fist” — should be reviewed prior to the game. EMS and athletic programs should agree upon the method of spinal motion restriction and the plan to leave on or remove protective equipment. This discussion should occur during EAP drill preferably or at minimum at the pre-game “time out.”
  • Research has also shown that the traditional methods of placing athletes on a spine board may not be the best for spinal motion restriction. The recommendation from the NATA is to use the “8 person lift” for placing a supine athlete on the movement device. Log rolls have shown to induce spinal motion and are thus no longer recommended. If the patient is in the prone position, the recommendation is to have a single motion roll from prone directly on to a device. Remembering that each movement increases the chance of injury so the single roll is preferred.
  • Another topic is the field removal of helmet and pads. The helmet-shoulder pad combination should be considered as a single unit and if the helmet gets removed, so should the shoulder pads. The crust of this thought is to have the most experienced people with the equipment be there to assist. Many emergency departments have never trained on this so this puts the athletic trainers and EMS in the forefront to make this happen.

This discussion has far reaching implications on many levels and the N.C. Office of EMS is having ongoing dialogues with the N.C. State High School Athletic Association and also the N.C. Department of Public Instruction. It’s the goal to develop committees that will represent the professions and the athletes to provide a forum for improving the prehospital care of athletes.

Jeff Hinshaw, MS, PA-C, NREMT-P is the chief PA in the Emergency Department at Wake Forest Baptist Medical Center. He brings almost 30 years of prehospital experience working in urban and rural EMS systems. He also serves as a workgroup consultant with the North Carolina Office of EMS and is a member of the Sports Medicine Staff for Wake Forest University Athletics.Dr. Winslow graduated from Emergency Medicine residency from UNC-Chapel Hill in 2002 and completed his EMS Fellowship in 2003. He has worked at Baptist Hospital in Winston-Salem for the past 11 years. He was appointed as the Medical Director of the NC Office of EMS in 2011. This document contains all protocol, procedures, and policies for all EMS agencies in North Carolina.

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