Nov 17, 2017
Gut Check
Nik Berger and Amy Bernard

By now, most athletic trainers know how to provide immediate care for a football player who’s suffered a severe head or neck injury. They are familiar with football equipment removal and spine boarding, and they practice these protocols regularly. However, ask those same athletic trainers to enact similar procedures in an ice hockey setting, and things can get a little dicey.

The problem is, many athletic trainers do not have experience working with ice hockey. Further complicating matters, little information has been published on properly removing hockey equipment or spine boarding on the ice.

But to keep up with industry standards, we have to learn. After all, the NATA included removal of hockey equipment in its 2015 recommendations regarding prehospital care of the spine-injured athlete. And several professional organizations, such as the Korey Stringer Institute and the National Federation of State High School Associations, have encouraged the development and practice of an emergency action plan for catastrophic injuries suffered in athletics — including on the ice.

With these factors in mind, the athletic trainers at Premier Health/Miami Valley Hospital in Centerville, Ohio — which provides sports medicine coverage to four high schools that offer ice hockey — decided to enhance our knowledge of the ins and outs of working on the ice. To do this, we planned and implemented an educational training session for our health care providers in November 2016 at a local rink.

Not surprisingly, there was a lot to learn. But we all walked away from the training better prepared to handle an on-ice emergency and excited to share what we had learned with our peers.

PLANNING PROCESS

The first step in organizing the educational workshop was determining who would attend. We elected to invite Premier Health/Miami Valley’s athletic trainers and emergency medical services (EMS) coordinators, hockey players, a hockey official (who is also a paramedic), coaches, ice rink personnel, and local EMS departments.

Though it is often overlooked, the safety of the medical staff while on the ice is a major concern. Not only can the athlete be further injured if a medical provider slips and falls on them, but the potential for falling puts the provider at risk of injury, as well.

Bringing together these people from multiple educational backgrounds and experiences provided everyone with new perspectives and skills to consider. For example, athletic trainers brought a vast understanding of sports injury stabilization, athletic equipment, and equipment removal techniques. Meanwhile, EMS personnel were well-versed in cot operations, emergency equipment operations, and rescue techniques. And the sport-specific knowledge hockey coaches, players, and the official brought was essential in creating realistic injury scenarios.

Several years ago, it would have been difficult to bring these different groups together. There was a lot of confusion and misconceptions about each discipline’s background, education, and role. Fortunately, the fact that we have spent time networking with these groups made planning the educational session much easier.

For instance, Premier Health/Miami Valley athletic trainers and EMS coordinators have met with local fire departments annually for the past few years to discuss and practice emergency protocols and action plans. At first, the focus was primarily on removal of football equipment, which led to training in treating exertional heat illness and the removal of lacrosse equipment. Adding the extrication of an injured athlete from the ice seemed like the logical next step.

Another area in which networking proved fruitful was securing ice time for the workshop — one of the biggest challenges with planning the event. Luckily, several of our athletic trainers have developed relationships with ice rink personnel over the years while covering hockey games. Because of this, the ice rink staff was willing to accommodate our needs.

SAFETY FIRST

Once we were ready for the educational session, we decided to split it into three segments. The first section included a lecture where we identified the risks inherent to both the medical personnel and the injured athlete when working on the ice.

Though it is often overlooked, the safety of the medical staff while on the ice is a major concern. Not only can the athlete be further injured if a medical provider slips and falls on them, but the potential for falling puts the provider at risk of injury, as well.

Most of our athletic trainers at the workshop had never approached an injured athlete on the ice, so they didn’t know how different ice surfaces would affect their movements. Ice that has just been resurfaced is extremely slick. Conversely, ice that has been played on is snowier, making it easier to gain traction. Regardless of the ice’s condition, it is Premier Health/Miami Valley’s standing protocol that all athletic trainers wear ice spikes when working hockey. So at the training, we made everyone familiar with these footwear attachments and where to purchase them.

While discussing safety issues, we quickly realized that approaching an athlete on the ice was not the only concern attendees had — many weren’t sure how to handle the razor-sharp hockey skates. We explained that when dealing with an athlete wearing skates who is being transported via EMS, the blades need to be covered with either a towel or skate guards.

Another safety concern dealt with the environment inside hockey rinks. We informed attendees that most rinks have ambient temperatures in the 50s or 60s, which can feel a lot colder if they are on the ice for an extended period of time treating a severe injury. For that reason, we suggested they plan on wearing clothes that would keep them warm and dry. Long pants are a necessity when working hockey, and it’s a good idea to dress in layers that can be removed or added to keep comfortable. In addition, we advised our personnel to keep towels on hand to prevent frostbite in case they had to kneel on the ice.

When it came to the safety of the injured ice hockey player, we encouraged our medical providers to remember the complications that can accompany traumas in a cold environment. Players will often be wet from sweating, and exposing them to the ice during treatment can cause significant issues, such as shivering or hypothermia. Depending on the athlete’s condition, it might be better to immediately get them into a warm, stable environment before treating their ailment.

FULLY EQUIPPED

The second part of the workshop delved into the specifics of equipment removal for hockey. This was especially important for the EMS personnel in attendance, since they were less familiar with equipment removal protocols. One thing is for certain: the time to figure it out is not on the ice during an emergency, as any unnecessary movement or delay in care can be disastrous for the injured athlete.

We had a parent set up a station at the training that went over the basic equipment hockey players usually wear. This gave the attendees a chance to see the various pieces of equipment up close, practice removal strategies, and discuss the challenges of getting the gear off.

Next, we addressed the common misconception that removing hockey equipment is just like removing football equipment. While both sports have chest and head protection that needs to be taken off to access the chest and airway, it is less rigid in hockey. And unlike football shoulder pads, the ones for hockey can be customized to fit each athlete’s body. This makes hockey shoulder pads easier to take off, often without disturbing the cervical spine.

In addition, hockey helmets differ from their football counterparts because they have thinner profiles, lighter weights, and full facial protection that extends below the jaw line (at least in the middle school and high school levels). Further, air bladders in football helmets can be deflated easily to assist with removal. This is not the case for hockey helmets.

Goalie equipment is a different animal entirely, as it’s bulkier and more cumbersome than other players’ gear, and generally consists of thicker shoulder and chest protection. Goalies’ helmets extend past the jaw line, with chin and throat protection, which can make maintaining cervical spine stabilization difficult. A goalie will also have a catcher (similar to a baseball glove), a blocker (equivalent to a shield), and additional leg protection that must be removed prior to securing the body for emergency transportation.

Regardless of whether the athlete is a position player or goalie, dealing with equipment personalization should be one of the biggest considerations when removing hockey gear. This is a challenge because players’ equipment may present differently depending on how it’s been modified. For instance, arm pads may be altered to cut down the length of the shoulder pads, a chest protector strap may be removed, or front or back plate padding may be reduced. We advised attendees to expect the unexpected when cutting off a hockey jersey and plan to adjust accordingly.

Another challenge we addressed at the training was making sure medical personnel had the proper tools to actually take off the hockey equipment. Facemasks and helmets require tools for removal, such as screwdrivers, and trauma shears are often needed to cut off shoulder and chest protection — bandage scissors just won’t work on this gear. If the medical provider doesn’t have the proper tools, it can delay treatment of the injured athlete.

ON-ICE PROCEDURES

To wrap up the workshop, we headed to the ice. The learning objectives for this third session were to demonstrate and discuss full-body immobilization of an injured hockey player and practice effective and controlled extrication from the ice to a transport device. Holding this training on the ice was key because this surface can present several challenges that cannot be reproduced on a gym floor or in a conference room.

When selecting an appropriate removal technique, we informed our workshop attendees that the care providers, number of rescuers, and tools available should dictate which one is used. For the sake of the training, we practiced an ideal emergency management situation that involved a minimum of four rescuers.

The practice scenarios included an athlete who was injured in the net and another where an athlete “crashed” into the boards and was prone on the ice. These were chosen because they are two likely instances in which hockey players can be hurt.

As far as extrication techniques, there are several different ways an athlete can be treated. If they are lying on the ice, one option is to have a rescuer maintain cervical spine alignment at the head while the other rescuers work at the torso and legs. A spine board is placed between the rescuers and the athlete. Once the victim is logrolled toward the rescuers, the spine board is placed under them. This method allows the board to be stabilized against the rescuers, which reduces the chances of the board slipping. The player is rolled over, positioned onto the spine board, and secured.

Then, the spine board can be used as a sled to safely remove the athlete from the ice. Using straps and moving feet first, one rescuer pulls the athlete slowly toward an exit point off the ice, while another rescuer pushes slightly from the other end so the board slides in a controlled fashion. This procedure prevents medical providers from lifting and carrying the athlete on the ice, which can be dangerous. Once off the ice, the medical staff can lift and transfer the athlete to a gurney. A gurney can be hard to maneuver on the ice since the wheels aren’t able to gain traction.

If there are fewer than four medical personnel present, extrication techniques need to be altered, and coaches and players will likely have to be part of the rescue team. Should this occur, the athletic trainer must verbally communicate and direct the rescuers, while taking the lead in providing care.

Nonverbal communication can also be a useful tool for expediting care between the medical providers on the ice and those who are gathering equipment off the ice. It’s important that all parties understand and know nonverbal cues during an emergency situation. These can be decided upon and practiced beforehand. For instance, forming an “X” with the forearms in front of the face could indicate a gurney, backboard, or splint is needed. A closed fist overhead could mean additional people are required to assist an athlete off the ice but that no emergency equipment is needed.

FEEDBACK & ADVICE

After the training concluded, we got a feel for what the attendees thought. Those who were not familiar with the ice were surprised at how difficult it was to maneuver safely while trying to quickly and efficiently stabilize a victim. Others were amazed at how cold the rink environment was. Despite these surprises, the attendees were more confident in their abilities to handle an on-ice emergency and appreciated the chance to experience that setting.

For others looking to set up a similar training, remember that it can’t be planned overnight. Ice time at most rinks is difficult to obtain and may need to be scheduled several months in advance. This applies to booking EMS personnel, as well. Their training calendar can be planned up to a year ahead in some cases. Securing ice spikes for the session can also be a challenge. Local vendors may not carry them, so you cannot count on purchasing them the day of the workshop.

In summary, medical professionals know that when it comes to properly caring for a cervical spine-injured athlete, there is often only one chance to be successful — and that applies to the ice hockey player, too. Everyone from the athletic trainers and EMS providers to the rink personnel and coaches are responsible for providing a safe environment and collaboratively managing any emergencies on the ice. For that reason, take the time to properly create an emergency action plan for the venue, and practice the game plan to care for injured athletes.

This article first appeared in the October 2017 issue of Training & Conditioning.

Image by Skeaze

Nik Berger, MS, ATC, is an Athletic Trainer at Atrium Medical Center in Franklin, Ohio. Previously, he served as Lead Athletic Trainer at Premier Health/Miami Valley Hospital in Centerville, Ohio.Amy Bernard, MS, ATC, PES, is Manager of Sports Medicine-South Region at Premier Health/Miami Valley Hospital in Centerville, Ohio. She can be reached at: [email protected]PremierHealth.com.


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