Controlling Catastrophe

Your emergency care plan could mean the difference between life and death for an injured athlete.

By Dr. Melvin C. Dace, Chip Howard, Greg McGarity, and Chris Patrick

Melvin C. Dace, MD, FACP, is the Chief of Stadium Medical Operations for the University of Florida and was the Assistant Medical Director for the 1996 Olympic Games in Atlanta, Ga. Chip Howard is the Assistant Athletic Director, Greg McGarity, the Associate Athletic Director, and Chris Patrick, ATC/L, the Assistant Athletic Director of Sports Health, all at the University of Florida.

Training & Conditioning, 11.6, September 2001,

Imagine the following scenario: Practice is going well when, all of a sudden, an athlete is down. He is not breathing, has no pulse, and is unresponsive. He is a victim of sudden cardiac death syndrome and how you react in the next eight minutes determines whether he will live or die. Do you have a plan for handling this situation? Is it in writing? Does everyone in the athletic department know it by heart, backwards and forwards, so that at any practice or event there is always someone who can instantly react to an injured athlete?

The emergency care of student-athletes is the most important component of a safe athletic medical program. And while developing an emergency care program may seem difficult, it is not. Many times, it's simply a matter of gathering existing procedures and putting them formally into one central document, then testing and refining that document with as many people as possible.

At the University of Florida, we recently completed the first phase of compiling our master emergency care plan. While working on our plan, we relied on the NCAA's Emergency Plan Template, which was completed in 2000 by Ron Courson, ATC, PT, NREMT-I, CSCS, Director of Sports Medicine at the University of Georgia, and his staff. Courson has extensive experience putting together emergency plans, including being instrumental in developing a plan for the track and field events at the 1996 Olympic Games.

Our master emergency care plan runs approximately 50 pages and took us roughly two years to put together. Obviously, there were long stretches of time when the plan was merely being tweaked or hardly worked on at all, so you shouldn't view it as an all-consuming project. By taking a step-wise approach, you'll see that putting together an emergency care plan is well within the reach of any athletic department.

The Basic Elements
The first requirement for a successful emergency care plan is an athletic administration dedicated to taking ownership of and providing support for the school's overall medical program. Accompanying the actual emergency care plan must be a sound underlying medical policy. A big part of this policy is the administration's responsibility to minimize the risk of injury and ensure proper medical care for emergencies, which will certainly occur.

The sports medicine director (SMD) (usually the head athletic trainer) is most often the person responsible for creating the plan. But in order to ensure that the plan is as comprehensive as possible, the SMD must get input from as many people as possible.

The SMD must act as both information conduit and creative director during the plan's formulation. It is particularly critical that the athletic director (or an assistant) take a strong leadership role behind the plan and be included in all phases of putting it together. The SMD will have the most medical experience and can best envision the measures that will need to be taken in emergencies, but leaving administration out of the loop will result in a nice plan for the athletic training staff that lacks enforcement and has little meaning outside the athletic training room.

In addition, any plan for the emergency care of athletes must include the constant participation of a wide range of people--athletic trainers can't provide complete emergency coverage by themselves. Most regular-season practices and games have qualified athletic trainers and, frequently, physicians in attendance. The NCAA, however, has pointed out that non-traditional season practices, skill instructions, and strength and conditioning workouts frequently do not have adequately trained personnel present to handle medical emergencies. It also noted that in sports such as track and cross country, many institutions (40 percent) did not have adequate medical coverage.

Although it is not feasible to have athletic trainers cover every athlete in every activity, provisions for handling emergencies must still be included in the emergency care plan for every athletic event, no matter what the size. It is important, then, for plans to address the need for individuals other than athletic trainers to be equipped to handle a variety of emergencies.

For example, we train all our head coaches, assistant coaches, and graduate assistants in CPR and first aid. If your program has certain sports where participants are some distance from athletic trainers or an athletic training facility, the student-athletes themselves should also be trained in CPR and first aid. These sports may include golf, track, cross country, and tennis. Although these policies reflect suggestions in the 1998-99 NCAA Sports Medicine Handbook outlining appropriate medical coverage, a study by the NCAA showed that less than half the member schools have implemented this safety recommendation.

Coaches trained in CPR and first aid are an extremely important part of any emergency plan. Coaches, though, are often reluctant to take the time to get certified. This is one example of the importance of the administration's role. The athletic director, not the athletic trainer, must be the one to insist that the coaches are trained in CPR. If the plan and the basic reasoning for their being trained in CPR are correctly explained to the coaches by administrators, there will be no objections. As a last resort, I have found that once you tell people that the person they are most likely to use CPR on is a member of their own family, resistance quickly disappears.

Bystander CPR is a key element in all successful resuscitations, so the more people trained in CPR and first aid, the better. If you are unsure of how many people in the department should be trained, it is best to err on the side of training too many people, because you cannot be too well prepared for an emergency situation.

Although we feel that coaches, assistant coaches, graduate assistants, and, in some instances, student-athletes should be trained in CPR and first aid, the athletic trainers form the backbone of any emergency plan. The athletic trainers should be able to perform at the highest level in CPR, first aid, and OSHA measures. They should understand and be able to carry out the emergency plan without hesitation.

To this end, the University of Florida has added the requirement that athletic trainers be educated in the use of automated external defibrillators (AEDs). Early bystander CPR and the time to first defibrillation have been shown to be the chief determinants of survival in cardiac arrest due to ventricular fibrillation. This means that defibrillation has moved from an advanced life support (ALS) to a basic life support (BLS) function.

It is our feeling that athletic trainers should be taught how to use AEDs in case of the infrequent, but absolutely devastating, event of cardiac arrest in the student-athlete. AEDs are easy to use, essentially foolproof, small and light, easy to maintain (the battery is the only thing to check periodically), and relatively inexpensive (about $3,000 each). Learning to use an AED significantly upgrades an athletic trainer's ability to handle emergency medical situations.

The new AEDs have been shown not to discharge unless ventricular fibrillation is present. They also record whatever cardiac rhythm is present even if it is not ventricular fibrillation, which is valuable information to have.

You may hear that athletic trainers cannot be taught to use AEDs. Nothing could be further from the truth. High school students, police officers, flight attendants, and lay people from all walks of life have been trained in their use, so athletic trainers can certainly be taught how to use them. Finally, Good Samaritan Laws have been written in most states (47, at last count) providing immunity from prosecution should something go wrong while using an AED.

We recommend that athletic trainers enroll in the American Heart Association Early Defibrillation Program. Retraining is done at appropriate intervals with hands-on skills-retention assessment. Manufacturers of the devices are also certified to train people in their use, although usually in smaller groups than the AHA.

Having this foundation of a well-trained staff in place will give you the greatest ability to execute emergency procedures effectively and efficiently. Although counting on help from others is key in both developing and executing the emergency plan, the SMD must be the one to develop and test the plan. His or her ability to carry the plan to fruition depends on having a vision of what the plan should be and the ability to transmit that vision to the rest of the team. The team, in this context, includes not only the athletic training staff but also the athletic administrators, coaches, student-athletes, fire/rescue chiefs, police, EMS, and others depending on your situation. Without everyone working together, the emergency program will have significant problems and some areas may not be properly covered.

The SMD must communicate with local fire and rescue chiefs to obtain their input on the best and quickest way to summon them in an emergency. They will be able to provide excellent input to your plan. The SMD should also discuss the plan with the university and local police chiefs--the police are often summoned to help in an emergency situation (for example, for crowd and traffic control).

As mentioned, the NCAA's Emergency Plan Template is an excellent resource for seeing what a plan should look like. In addition to a general discussion of what needs to go into a plan, the template includes sample summary plans for both a baseball and coliseum venue. Using a template allows you to develop some generic concepts that can then be tailored for each specific sport and your institutional needs.

Although the exact structure and content of your plan will be based on the needs and conditions at your school, all emergency plans must include such things as contact numbers in case of emergency (how to reach emergency services, as well as family contact information for every athlete); site-specific maps for each venue with locations of phones, exits, and best route to the hospital clearly marked; directions on how to direct someone to and around the venue; and, for some venues, a section on lightning safety. Deciding on the distribution of your AEDs among the athletic training rooms, gymnasiums, and fields is also important, and should be covered in your plan. This is based on the particulars of your campus and how many AEDs your institution has on hand.

The plan must also include information on what to do after a medical emergency. Who needs to be told about the incident and how soon? What is the procedure for documenting the event, including who writes the report and what needs to be included in the report?

As these issues are thought through, the SMD will be able to begin drafting a general emergency plan that includes all of the above-mentioned elements, including a background section on who needs to be trained and why. It should be as comprehensive as possible--for example, our plan includes five pages just on AEDs--but you will find that it will still require lots of fine-tuning. The next step is to distribute this draft to as many people throughout the athletic department as possible.

Once everyone has had a chance to review it, break the department into groups, such as coaches and athletic trainers who work in the same venue, and possibly include one or two of their student-athletes. Then, put each group through the paces to test how the plan works during an actual emergency. This is usually done at a sit-down meeting where the SMD and, often, the athletic training staff, come up with emergency scenarios and ask participants to respond appropriately based on the plan.

These meetings can get very stressful, but emphasize to participants that the goal is not to test the participants as much as it is to test the plan. The overriding concern is that the emergency plan must be able to answer everyone's questions in regard to any emergency that could possibly arise. You will quickly find elements that the plan doesn't cover--and that need to be added.

Run through such things as who does what, where are phones located at each facility, who is called, what's done--and by who--until EMS arrives, etc. The available use of radios, cell phones, university phones, and public telephones must all be carefully planned for and clearly documented for each venue. And don't forget backups for both people and equipment because phones sometimes fail to work and a team member may not be able to perform his or her duty.

Some sports (again, such as golf and cross country) will have unique requirements that will need to be addressed. Start gently, with easy scenarios, and then move on to more involved, and even unlikely, ones. And keep in mind that the plan must address all home and away practices and events. Obviously, the discussion about away events would not have to include the kind of detail you need for home events, but at the least, there should be a mention of the chain of order of who to notify and when if an emergency occurs.

You should also include the procedure for contacting athletic trainers at all away events. For example, we contact the other school's athletic trainer who will cover a given event a few days before and check what kind of coverage they will have. Then, when our athletic trainer arrives on-site, he or she will go over such things as where all the emergency equipment is located.

These meetings and the discussions they foster will allow you to create specific plans for each sport and venue. Many of these will be redundant, but it is important that everything be spelled out for each specific user. Having one generic plan that isn't broken down for each sport and venue will give users too much information they don't need, which will only confuse them.

Final Touches
After the plans are revised to cover everything that came up at these meetings, they must be distributed and reviewed with everyone involved. It must also be decided where copies of the plans will be kept. Even though you should be able to count on personnel being trained on how the plan works, it must be readily available to anyone who needs it in case of an emergency.

The plan should not be published as a fancy, hard-bound book. We chose to simply put ours in a three-ring binder, because it's the easiest and cheapest alternative, and the binder allows you to easily update the plan.
At the very least, a complete copy, covering every sport and venue, should be kept in the athletic director's office, each athletic trainer's office, and every athletic training room. Summary venue plans, including maps showing exit routes and locations of any emergency equipment such as phones and fire extinguishers, along with emergency phone numbers, must be clearly posted at each venue.

In addition, I would recommend that your plan be reviewed by legal counsel to be sure it is medical-legally correct. An example would be promising a medical outcome you can't be sure of. A small point perhaps, but an important one.

Staff must also regularly review the plan--at least annually. Training and re-training of all involved personnel is necessary at appropriate intervals. I can assure you, sport emergency care will change and you must be willing to annually review and revise your plan accordingly. For example, our athletic trainers meet twice a year with our Fire/Rescue Chief. At these meetings, emergency procedures are reviewed. As a result of these meetings, all ambulances and police cruisers now carry laminated maps of our athletic complexes so there is no time lost in getting to the site of an emergency. This small effort may quite literally make the difference between life and death.

By taking it a step at a time, and enrolling the backing of the athletic administration, you will find that putting together a comprehensive emergency medical plan is not very difficult at all. It is a sum of these small efforts that will ensure your institution is as prepared as possible for any medical emergency.