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April 2002


Covering Your Bases

By Robb S. Rehberg, MS, ATC, CSCS, NREMT
Sports medicine professionals must plan in advance and maintain assessment skills to best treat seriously ill or injured athletes.

Caring for medical emergencies is perhaps one of the most frightening aspects of a sports medicine professional's job. Unlike routine care for chronic injuries, medical emergencies are never scheduled and they require knowledge and skills not often used in a typical workday.

In order to provide the best possible care for a seriously ill or injured athlete, sports medicine professionals must possess the skills and knowledge necessary for handling such situations, and they must be ready at all times. There are two parts to sports emergency care readiness: preparation and management.

Preparing For The Unknown
Of course, being prepared is an important part of any job. However, when life-threatening situations are involved, preparation and planning take on new meaning. Planning for emergencies is a continuous practice that must begin well before the season starts. Most people are familiar with the 5 Ps of planning-prior planning prevents poor performance. In planning for sports medical emergencies, the five Ps take on new meaning: plans, protocols, products, personnel, and practice.

Emergency action plans are essential to emergency preparedness, regardless of setting. As the name implies, they should serve as a guide as to what actions must be taken in an emergency. The plan should be written clearly and concisely (usually no more than one page), and should identify specific actions that should be taken. Information such as how to notify emergency medical services (EMS) and locations of the nearest telephones, first aid kits, and automated defibrillator are commonly included in the plan. It should also have instructions for nonmedical personnel on how to care for a victim until help arrives. Since the physical and logistical characteristics of sports venues vary, a separate plan should be written for each.

Written protocols for handling medical emergencies should be developed and shared with all members of the sports medicine team. Unlike the emergency action plan, these protocols serve as a guide to providing emergency care for specific situations. Many organizations develop protocols for management of situations including spine-injured athletes, cardiac arrest, and drowning. These protocols should be developed in conjunction with the team physician and the local EMS that will be responding to the emergency. It is important to share this information with each member of the sports medicine team. The time to find out that team members disagree on treatment protocols should never be during an emergency.

Ensuring that the proper emergency medical equipment is available at all times is important. At a minimum, a cardiopulmonary resuscitation (CPR) mask, gloves, and communication equipment (cell phone or radio) should be available at all times. If the sport requires a helmet as in football, lacrosse, and hockey, an appropriate tool for removing the facemask should be available. Advanced equipment such as adjunctive airway devices and diagnostic equipment should be available if personnel are trained in their use. In order to ensure the proper equipment is available, consider building a separate emergency kit instead of using supplies from a commonly used medical kit. The availability of an automated external defibrillator (AED) is also recommended. In fact, legislation has been proposed in several states and enacted in at least one (Pennsylvania) that requires AEDs be present at high school athletic events.

Becoming familiar with all health care providers who will be involved is another integral factor, and even more important is knowing that these professionals can work well together. The sports medicine team should include physicians, certified athletic trainers, therapists, emergency medical technicians (EMTs), and paramedics. The team should also include coaches and players. Coaches can be a valuable asset during an emergency by providing reassurance to an injured player or helping secure the scene. Players should not be overlooked, and should be educated on safe play, what to do if they are injured, and, most important, never to move an injured teammate. Just as practice is key to the success of any athletic program, so is practice essential for members of the sports medicine team. The team members should practice often and together.

Managing Medical Emergencies
Care given in the first few minutes of a medical emergency can ultimately determine the ill or injured athlete's outcome. A victim of a medical emergency has the best chance of survival if a prompt assessment is made, followed by appropriate care. Although managing a medical emergency may seem complicated, it can be made easy by using a systematic approach. One such approach I have developed is to learn to REACT: recognize, EMS, assess, care, and transfer.

Recognize. Witnessing the mechanism of injury can be of great value in an on-field assessment. It is important to pay attention to the game and continuously look for mechanism of injury. This requires watching an event or game as a sports medicine professional and not as a spectator. When approaching an ill or injured athlete, pay close attention to the situation. Assess the scene safety. Although remote, hazards such as electrical shock, environmental hazards such as lightning strikes, or even chlorine gas around a swimming pool can pose a risk.

Remember that your health and safety come first. Always take body substance isolation precautions by using protective equipment like protective gloves and a CPR mask. These should be carried at all times. Notice the number of injured athletes, as well as the athlete's position and disposition. Then begin to make a mental note of what special tests, equipment, or additional personnel may be needed. Consider cervical spine stabilization at this point. Finally, determine the need for additional help, such as EMS or police.

EMS. If the injury is serious and it is obvious that additional help is necessary, call for EMS by activating your emergency action plan. Be sure to provide information such as the nature of the injury, location of the victim (be as specific as possible), and care being given. Also provide a callback number in case the dispatcher has any additional questions.

Assess. Recent innovations in emergency care have prompted new ways to perform athletic injury assessments. Emergency Medical Technician-Basic: National Standard Curriculum is the basis for nearly all EMT training in the United States.1 In this curriculum, EMTs are taught a systematic method of assessment. This system can also be used by sports medicine professionals to assess athletic injury or illness. In fact, becoming familiar with the EMT assessment provides a common understanding of the assessment process, and increases the ability of sports medicine and EMS professionals to work together effectively.

Begin to form a general impression of the athlete immediately, and determine the athlete's chief complaint and correct any apparent life threats. As you begin the initial assessment, note the athlete's level of responsiveness using the AVPU scale. Is the athlete alert (A), does she respond to verbal (V) or painful (P) stimuli, or is she unresponsive (U)?

Next, the ABCs (airway, breathing, circulation) should be assessed. If there is an absence of breathing and/or pulse, CPR or rescue breathing should be initiated immediately. Otherwise, assess and make note of breathing rate and quality, pulse rate and quality, and skin color, temperature, and condition. At this stage, a decision should be made as to how serious the athlete's condition is and whether it warrants rapid transport (as in a cardiac arrest) or further on-field evaluation (as in common orthopedic conditions).

If indicated, a baseline set of vital signs including pulse and respiration rate and quality, blood pressure, and skin color/temperature should be obtained. A SAMPLE history should also be done, asking patients about symptoms (S), allergies (A), medications they are currently taking (M), past medical history (P), last food or drink (L), and events prior to the injury (E). This information should be recorded as soon as possible, especially in athletes with a head injury or an altered level of consciousness. This valuable information will be unobtainable if the patient becomes unresponsive.

If the situation involves an injury, a trauma assessment is indicated. Depending on the severity of the injury, a rapid trauma assessment can quickly identify major injuries not revealed in the initial assessment. A head-to-toe evaluation may now be performed using the rapid trauma assessment, visually inspecting and palpating. Look for DCAP-BTLS: deformities, contusions, abrasions, punctures or penetrating wounds, burns, tenderness, lacerations, and swelling.

If the situation involves acute illness, a medical assessment should be conducted. Additional information should be obtained using OPQRST: onset or how and when the pain began; provokes, what makes the symptom worse; quality, or how the athlete describes the pain (ie, dull, throbbing); does the pain radiate; the severity of the pain; and what time the pain began. This information should be recorded, and the athlete should be reassessed every 5 minutes until care is transferred.

Care. Based on the information obtained in the assessment phase, appropriate interventions can be initiated. No matter how serious an injury may be, airway, breathing, and circulation always take precedence. Care should always be guided by the written protocols in place as discussed earlier. As care is being provided, the athlete should be continually reassessed, being watchful for any improvements or declines in vital signs or assessment findings.

Transfer care. Whether it is to an EMS crew, physician, or other health care professional, you will be transferring care of your ill or injured athlete at some point. In doing so, be sure to provide all the information you have gathered. This information will be important as further care is administered to the athlete. If possible, provide a copy of vital signs, SAMPLE interview, and any findings from your DCAP-BTLS or OPQRST assessment.

As a sports medicine professional, the least used but most important aspect of your job may be that of providing emergency care. By planning in advance and maintaining assessment skills, you will be better prepared to handle sports medical emergencies. Ultimately, however, the planning, practice, and training will most benefit the athletes you serve. It may even save a life.

Reference
1. US Department of Transportation. Emergency Medical Technician-Basic: National Standard Curriculum. Washington, DC: National Highway Traffic Safety Administration; 1994.

Robb S. Rehberg, MS, ATC, CSCS, NREMT, is the director of emergency medical services at Montclair State University, Upper Montclair, NJ, and the head athletic trainer at Westwood Regional High School in Westwood, NJ. He also serves as an EMS educator and consultant and an athletic training clinical instructor, and is currently the chairman of the National Safety Council First Aid Institute Board of Advisors. He may be reached via email: robb.rehberg@montclair.edu.

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