Sep 25, 2017In An Emergency
There is no time for turf wars between athletic trainers and EMS when an athlete’s safety hangs in the balance. Here’s how you can work together seamlessly with your local crew.
This article first appeared in the October 2017 issue of Training & Conditioning.
An emergency medical technician (EMT) with white hair and a handlebar mustache stood in front of me smiling. “Don’t worry, kid,” he said. “We’ll take care of the players. You can go back to training them.”
As a newly certified athletic trainer in 1996, this was my first introduction to a volunteer emergency medical services (EMS) ambulance crew at a high school football game. Although the man addressed me in a friendly-not demeaning-way, I was still taken aback by what he said and didn’t know how to respond. So, I did my best to educate the EMTs at the game about who I was and what I could bring to the health care team. Then, I made sure I had an “elevator speech” ready for the following week. My approach didn’t solve the issue entirely, but it was a start.
Times have changed since then, and athletic trainers have become much more common at high schools across the country. But despite this progress, working effectively with EMS providers often remains a struggle. Part of the problem is a mutual lack of understanding about what each group offers, and part of it is an absence of any existing foundation to build a relationship upon.
Of course, that doesn’t mean it’s impossible to create positive partnerships. The starting point is remembering that athletic trainers and EMTs are on the same side-both are medical professionals who have the best interest of the athlete in mind. Then, with a proper understanding and respect for each other and a willingness to reach out and make connections, the two groups can collaborate seamlessly.
CLEARING THE AIR
Before we delve into how athletic trainers and EMTs can work together smoothly, we first have to tackle some of the issues standing in the way. Probably the biggest one is lingering misconceptions about both professions.
Through my 20-plus-year career as an athletic trainer and EMT, I’ve encountered numerous EMTs who mistook athletic trainers for personal trainers. I’ve also seen dozens of posts from EMS providers on message boards and social media platforms complaining about athletic trainers overstepping their boundaries when EMS is on the scene. This tells me that EMTs do not always understand the depth of athletic trainers’ qualifications and their value in providing medical care on the field. Although this is frustrating for athletic trainers, we must view it as an opportunity to better educate EMS about our profession.
On the flip side, I’ve heard many athletic trainers grumble that EMTs are simply “ambulance drivers” without the skills athletic trainers possess to evaluate sport-specific injuries. This is just as misguided as their assumptions about us.
EMTs are a critical link between the scene of an emergency and the health care system. They have the knowledge and skills to stabilize and safely transport patients ranging from non-emergency instances to life-threatening situations.
Further, just as not anyone can claim to be an athletic trainer, the same goes for EMTs. They must pass a rigorous training program before providing medical services. Nationally defined EMT standards mandate about 100 hours of training for EMT-Basic certification, 1,000 hours for EMT-Intermediate, and 1,300 hours for EMT-Paramedic. Most programs also require participants to hold CPR certification and undergo a criminal background check, as well as a medical exam.
MAKE THE CONNECTION
Once athletic trainers and EMTs have a basic understanding of each other’s skills, the next step is reaching out and working together. In some places, this has become policy.
For example, the New York State Department of Health recently issued a statement recommending “EMS providers [have the] knowledge and understanding of the role, responsibility, and capabilities of certified athletic trainers, so that when EMS is called to a sporting event, the patient will benefit from positive communication and consistent prehospital emergency medical care.” Within this directive comes the suggestion that EMTs and athletic trainers meet to improve relationships between the two groups.
So how can athletic trainers be proactive about this? Start by contacting your local EMS department to open a line of communication. This requires some understanding of the basic EMS organizational structure.
Both paid EMS squads and volunteer fire/ambulance departments generally have a similar setup, with a chief, assistant chief(s), captains, lieutenants, and other ranks. Many may have a “company,” which is usually a nonprofit corporation that includes a president, secretary, treasurer, and other officers. There may also be a board of directors or trustees that manages the business side of the organization.
The first person the athletic trainer should reach out to is the chief, EMS/training captain, or a company officer. If you are new to the area and unsure who this is, ask around to find someone who is in the fire department, possibly a coach, administrator, or parent. Be observant-look for an adult wearing a local fire department shirt-or even ask your school’s resource/safety officer. There’s always someone who knows!
If that isn’t successful, find your local fire department’s website or Facebook page. Either of these resources should list upcoming open houses and weekly training/work nights, and EMS squads usually open their doors to visitors and new recruits for these events. This is a perfect opportunity to introduce yourself and meet many of the officers.
From there, offer to conduct a presentation on sports-related emergency management protocols for the EMS squad. Pitch the partnership as an educational opportunity for everyone involved. The athletic trainer can learn about the fire department/EMS, and the fire department/EMS can learn about the athletic trainer. To make this an easier sell, have a plan in place-your availability to lead a training, how long it will take, and any expectations for the hosting facility (i.e., space needs, audio/visual needs, or any costs).
A popular option for the initial training session is a joint clinic on football equipment removal. Although many EMS crews might be familiar with the sport of football, few have physically worked with the equipment. Giving EMTs the opportunity to try on the gear, especially snug-fitting helmets, builds an appreciation for how difficult it can be to remove with minimal motion to the cervical spine. You can also let them practice cutting off the equipment by using old jerseys, laces, straps, or facemask clips.
Think EMTs won’t enjoy this opportunity? Think again. Many EMS departments conduct regular trainings and are often searching for ideas to develop new skills, provide interesting experiences, use different tools, and update old protocols. (Being part of a fire department, I can attest that we get bored with repeating the same old drills all the time.)
As the two groups become familiar with each other, continue building an open line of communication into the athletic season. One way to do this is by holding a health care provider “Time Out” before every athletic event, a protocol recommended by the NATA. This involves gathering the members of the emergency response team, going through a pre-event checklist, reviewing the venue’s emergency action plan, and determining where/what type of emergency equipment is available.
In addition, the Time Out should determine the role of each health care provider. For instance, it is generally accepted that the athletic trainer will request EMS, even if EMS is located on-site.
Another important point to address during the Time Out is how communication will occur. When tending to a serious injury at my high school, I sit up quickly and hold my arms crossed above my head to indicate a need for EMS and emergency equipment. Our EMS knows what to do when they see that signal. Other facilities may use radios or cell phones. Combined, these different elements of the Time Out can ensure a decisive, coordinated response and outcome in the event of an emergency or life-threatening injury.
Once the sports season is underway, don’t forget to keep in touch. Schedule regular meetings or skill sessions with EMS-even if it’s just to meet with the squad’s leadership to review protocols or introduce new equipment. For example, my school now has football helmets that require a special tool to remove the facemask clip, so I scheduled a training to make sure my EMS squad understood how to use it. This keeps the dialogue open, and you may find that EMS will eventually reach out to you with training session ideas.
When athletic trainers and EMS are on the same page, good things can happen. Here are four examples where these two groups teamed up and saw positive results, starting with one from my own experience.
• Before I became involved in EMS work myself, I began volunteering with my team physician at local athletic events, such as road races and 3-on-3 basketball tournaments. Through this, I met EMS professionals, and I was able to showcase my skills. As a result, the paramedic who organized the medical care for the basketball tournaments began to request athletic training services yearly. He also instructed the volunteer EMS students in attendance to watch me in action taping, evaluating, and treating injuries.
• Christina Emrich, MS, ATC, LAT, EMT, President of the Athletic Trainers’ Society of New Jersey and 2nd Lieutenant of the Tinton Falls, N.J., EMS-North, introduced her EMS squad to athletic training to avoid a repeat of the turf battles that had occurred in the past. She invited the athletic trainer from the local high school to an EMS training meeting. There, the athletic trainer informed the EMTs about the education and skills of athletic trainers, demonstrated football equipment removal, and showed how to move an athlete with cervical spine injury.
In addition to her EMS role, Emrich serves as Athletic Trainer and Assistant Athletic Director at Red Bank Regional High School in Little Silver, N.J. Red Bank’s emergency protocol requires EMS to follow the athletic trainer’s lead at an athletic event until transfer of the patient has been completed. Emrich and the Red Bank EMS squad (not the one she works for) review this protocol together every August during the preseason for fall sports. Usually, they try to schedule a training session where Emrich and the squad members go over the protocol and discuss where EMS will be stationed, as well as their role during football games. Prior to game time, Emrich meets with EMS to determine how she will communicate when EMS is needed, where EMS will enter onto the property, and how to handle radio communication when EMS is en route.
• Melissa O’Brien, MS, LAT, ATC, Lead Athletic Trainer at Cole Memorial Hospital in Coudersport, Pa., noted that when she began at Smethport (Pa.) High School 16 years ago, there were growing pains when working with EMS squads. However, by hosting annual summer clinics for local volunteer EMS, she was able to educate this group about athletic trainers. At the clinics, there are always presentations on concussions, sudden cardiac arrest, and equipment removal protocols. Other topics include shoulder/knee injuries, turf wounds, and so on. “EMS is now accustomed to having an athletic trainer present at the football games of our contracted schools,” O’Brien states. “They are surprised when no athletic trainer is present.”
• A few years ago, Kate Coupe, EMT-P, Chief of Services and Paramedic at the Granby (Conn.) Ambulance Association, reached out to the athletic director at Granby Memorial High School to go over medical protocols and services provided. She also met with the Granby Athletic Trainer Becky MacEwen, ATC, to discuss equipment removal and emergency assessment.
During the meeting, Coupe and MacEwen covered their respective capabilities to manage and treat medical emergencies based on the available staffing and equipment. They also discussed a variety of other topics, including how diabetic emergencies, heat and dehydration issues, head and spine injuries, and cardiac arrest might be treated, as well as what medications and equipment are carried by athletic trainers and EMS.
Taking the information gathered from MacEwen, Coupe went back to the Granby Ambulance Association and passed it along in a training session. To make sure the whole company received this information, Coupe e-mailed the highlights to any absent EMS staff. The e-mail included the roles, responsibilities, and capabilities of the athletic trainer; tips for working together and understanding how each mindset works; the current concussion/head injury protocol and recommendations for return to play; and the local EMS guidelines for treatment of any injuries and illnesses discussed.
As these examples show, it’s possible to establish productive partnerships between athletic trainers and EMS squads. Opening this door will benefit all, especially the injured athlete in need of expedited, immediate care.
IT TAKES TWO
In order to work together effectively, both emergency medical services (EMS)/emergency medical technicians (EMT) and athletic trainers have to modify their behaviors. As both an athletic trainer and EMT myself, here are some tips I have for how each group can adjust:
EMS/EMTs: Trust the experience and insight of the athletic trainer. They work day in and day out with athletes, and they likely know the athletes and their normal behaviors, pain tolerances, etc.
Also, believe what the athletic trainers witness. For example, I once worked a women’s football game where a player was tackled out of bounds-causing a brief hypoxic seizure due to an abdominal blow. Because the EMTs did not witness it, they did not believe that it occurred (even though I reported it). Because of that and other signs and symptoms the athlete was exhibiting, I insisted on a transport to the emergency department, where a small spleen laceration was found.
Athletic trainers: If EMTs seem to be going too slow or asking you unusual questions, this is generally due to local or state protocols. EMS must document specific items, and, in some states, their patient care report is reviewed for completion and correctness by local and state authorities. And don’t underestimate their experience with trauma and emergency cardiac care-their knowledge will only benefit your athletes.
Both: Get rid of your egos! EMS and athletic trainers each want what is best for their patient. In times of emergency, good medical care requires sound clinical judgment and teamwork. Your protocols may not always perfectly align, but this is not the time to argue. It is a time to compromise for the good of the athlete.
When working with emergency medical services (EMS), athletic trainers might be surprised to encounter differences in trauma protocols, such as spine boarding. In certain cases, EMS will no longer immobilize those with suspected cervical spine injury to a backboard. Instead, they may place the patient directly on a stretcher and transport them with only a cervical collar.
These protocols were changed for EMS in 2015 and were based on NEXUS (National Emergency X-Radiography Utilization Study) criteria. The reasoning for the shift is because full immobilization to a backboard is uncomfortable, even painful. It also increases the amount of time needed to transport the patient, puts them in a vulnerable position, and increases their risk of aspiration. Some studies have even shown that spine boarding is often unnecessary-according to the New York State Department of Health, 97 percent of 800,000 patients surveyed who were backboarded had negative cervical X-rays.
Now, the concept of “spinal motion restriction” versus “immobilization” in EMS protocols allows for various methods to be used. In New York, for example, a sports injury with spinal trauma needing spinal motion restriction would involve the use of a properly fitted cervical collar. Although a spine board could be used to transfer the athlete to the stretcher, the stretcher alone would provide adequate spinal motion restriction.