Jan 29, 2015Road Warrior
What’s it like to be an outreach athletic trainer for a group of rural high schools? To start, traveling light is not an option.
By Jodie L. Smith
Jodie L. Smith, MEd, ATC, CSCS, is an Athletic Trainer with Athletic Medicine & Performance in Billings, Mont. She can be reached at: [email protected].
When I went to college, I learned that the role of an athletic trainer was to “prevent, treat, and rehabilitate athletic injuries.” Working now as an outreach athletic trainer for rural high schools, that definition merely scratches the surface of what I do.
For the past eight years, I’ve been an athletic trainer at an orthopedic office in Billings, Mont. Some of my work is textbook and typical. But a good portion of my days are spent as the primary health care provider to children ages 12 to 18 who live and attend school in small, rural towns surrounding Billings.
Working in this capacity presents challenges. I see each group of athletes I treat infrequently. I’m often asked to examine injuries and illnesses I have never seen before. And I continually bump up against rural medical myths that can’t be easily brushed aside.
There are also many rewards. The high school football games–where the whole town comes out and embraces me as a member of their community–are great. And I am continually heartened by the knowledge that I am helping people in a significant way.
Overall, I’ve found that working in rural athletic training outreach requires being able to wear many different hats, employing great communication strategies, and a focus on educating others. The setting has also challenged me to learn a lot, professionally and personally.
I am employed by Athletic Medicine & Performance (AMP), a joint LLC of Ortho Montana, St. Vincent Healthcare, and Yellowstone Surgery Center, which provides sports medicine services to the Billings region, covering about a 100-mile radius. Our team is comprised of orthopedic surgeons, a sports medicine fellowship-trained family medicine physician, athletic trainers, physician assistants, a dietitian, and a number of strength and conditioning specialists. Many members of our team have multiple credentials.
Our outreach athletic training is a contracted service and varies from school to school. Some have coverage every day, others are on a once- or twice-a-week schedule, and still others change by the sports season. For example, a few schools only contract for outreach athletic training visits in the fall, but during the winter and spring, their athletic trainers will travel to the school when requested.
My job is three-fold. I am an outreach athletic trainer for seven rural schools, an assistant athletic trainer at a larger high school in Billings, and a clinic athletic trainer. My time spent with the rural schools is 20 hours per week in the fall and 10 to 15 hours per week the rest of the school year.
While my mornings change daily, I spend afternoons at my large high school. Every day is different for me, but my weeks follow a typical pattern.
Monday mornings are paperwork catch-up time, where I transfer my SOAP notes from hand-written form to electronic. Tuesday, Wednesday, and Friday mornings, I travel to rural schools, visiting the three larger ones (190 to 260 high school students) on Tuesdays and Fridays and the four smaller ones (nine to 80 high school students) on Wednesdays. These are all K-12 schools, so I sometimes see elementary and middle school students.
Thursday mornings I spend in the orthopedic clinic. During my shift, I teach home education programs, change post-op dressings, fit braces, take blood pressures and histories, and do whatever else the attending physician that day would like. There is a lot of variety on Thursday mornings.
At the rural schools, my primary job is to evaluate, diagnose, and develop a plan of care for injuries and illnesses. This can be as simple as prescribing some exercises or a brace, or recommending additional care by another health care provider. But more often than not, things are not so simple and I’m asked to step outside my athletic training role.
Of the seven schools, one has a full- time nurse and the rest have a traveling nurse who is there one day a week at most. The majority of the students in these schools do not have a primary care physician and seek medical care only in the case of severe illness or injury. For many of these kids, I have become their health care provider.
When I arrive at a school, there is typically a list ready and waiting for me of who needs to be seen. Students are pulled out of class and directed to whatever makeshift office the school can offer. I treat students on benches or chairs, on the stage in a gym, and in locker rooms, hallways, and libraries. I figure if I can do an evaluation in the middle of a muddy field in the pouring rain, I can manage with these spaces.
Last year, one of my schools converted an old storage room into an athletic training area. A local carpenter even custom built treatment tables for the space, which makes me smile every time I walk in. But the best part of having a dedicated area is that the physical education teacher posted my home exercise programs on the walls. When a coach calls me about an athlete’s injury, I can get them started on a treatment program by telling them to follow a certain program.
Along with evaluating student-athletes, I see teachers, coaches, staff members, and younger children. I once referred a six-year-old to our Pediatric Orthopedic Surgeon for a possible fractured humerus, and she was diagnosed with a Salter-Harris fracture in her proximal humerus.
Since I work with a population that is, for the most part, still growing, I see a fairly large number of growth plate injuries. These issues were not covered much in my college courses or textbooks. But with experience and through my work for an orthopedic office, I now know to look for them.
I am also presented with some of the best bruises, cuts, and abrasions you can imagine that have nothing to do with athletics. Livestock and fences are not the most forgiving things, I’ve learned. Injuries also frequently come from climbing trees, haystacks, and the occasional shed, as well as from jumping irrigation ditches. In addition, I have a number of athletes who rodeo on the weekend and come to me with their injuries.
Due to the atypical nature of my work with the rural schools, the strategies I use sometimes differ from the norm. To start, I have to fully recognize the culture of rural medicine.
Many of the student-athletes I see do not fully trust traditional medicine and there may be initial resistance to what I prescribe or recommend. Home remedies are widely accepted, and these practices range from harmless, to helpful, to harmful. It’s important that I understand them, which I do, thanks to being raised on a farm. (In fact, the most recent person who told me he was going to use livestock antibiotics on himself was my own brother!)
When a student-athlete relays that he or she has been using a home remedy, I listen with open ears and am careful to not immediately discount it. I gently try to educate them as to why or why not the practice may work or could be dangerous. When I offer an alternative, I explain it in detail and ask what questions they may have.
Sometimes, I have to take a “wait and see approach” with injuries. For example, if an athlete has a bad ankle injury, I will suggest an X-ray, but I will not insist on it. The culture against traditional medicine and the inconvenience (as well as cost) of going to a clinic or hospital for the X-ray means many parents will resist. In these cases, I hold the athlete out until I see them again and then decide if an X-ray is necessary. If it is urgent that the athlete get an X-ray, then I will push the parents to do so, getting sport coaches or administrators involved, as needed. But because I only send a small percentage of athletes for further medical care, when I say they need to go, parents tend to listen.
Another important factor I have to take into account with the rural population is that I am seeing the students infrequently. It is critical they are compliant without my oversight and take a lot of responsibility for their own care. Here again, education is key.
I believe that athletes are more likely to participate in their recovery if they understand their injuries and why we are treating them in a specific manner, so I explain everything in detail. I also tell them that if they are responsible enough to handle the privilege of playing sports (and in many cases, have drivers’ licenses), then they can and will be held accountable to their recovery.
I find it works best to keep rehabilitation exercises to a minimum. I often assign only two to three, and they rarely take more than five to 10 minutes a day. If I give student-athletes too much, they will say they don’t have time and will not do any of them.
Some exercises that I assign can be done in the classroom while seated at a desk, especially for athletes with an acute ankle sprain. Additionally, I have great weight training teachers in several of my schools. Often, we incorporate a student’s rehabilitation exercises into strength training, or I tell the teachers what I need strengthened and let them implement the exercises.
Good communication is key to being effective in the rural schools. Since it’s impossible to see every coach during my visits, I use a three-part carbon form to relay information. One copy goes to the parent, another to the coach, and I keep one. The athletes are responsible for delivering the notes to their parents, and, in some schools, to their coaches as well. It may seem old-fashioned, but it works.
The sheet contains my assessment, plan of care, and my cell phone number. I encourage parents and coaches to call me any time they have questions.
In fact, I often hear from coaches between my visits about new injuries. Sometimes, they text me pictures of an athlete’s swelling and bruising. I spend a lot of time on the phone, texting as much and as well as a teenager. I work on being really clear with my instructions.
Communication with other medical providers is also essential. When something is beyond my skill set, I have easy access to the physicians, physician assistants, physical therapists, and occupational therapists at AMP. Being able to call or text a question to a physician makes my job easier. Whenever an athlete sees another health care provider, I require a written note, and I often assist in implementing their plan of care.
A final part of the strategy entails tapping into the services of our clinic in Billings. AMP is committed to seeing athletes in a timely manner, and we continually re-evaluate how we can do better. A few years ago, a “bump clinic” was added on Monday mornings, designed to see acute orthopedic injuries from the weekend on a walk-in basis. Just recently, an orthopedic walk-in urgent care clinic was opened that includes evening hours. In addition, athletes can call and make appointments if they need to see a specific physician–all of our orthopedists are subspecialty trained.
My half-day of work in the clinic on Thursdays is also important. Being there offers continual education as I see many post-op cases and also get first-hand experience with tissue healing. I learn a lot by seeing why protocols are set a certain way. And I sometimes have the option of watching a surgery, which is hugely educational.
My knowledge from this experience allows me to follow-up with post-op student-athletes in my assigned schools, saving them a trip to the office and keeping them from missing classes. For example, if the surgeon normally sees his post ops every two weeks, I can see his patients in between visits, so their physician appointments can be made monthly. The teacher in me likes keeping them in school, but it also saves the parents both time and the cost of travel.
One injury takes extra special care. Concussions pose a huge challenge for all sports medicine teams but can be even tougher to handle in rural schools where there are fewer resources.
For several years, AMP has had the rule that all athletes with a concussion must be treated by a physician, physician assistant, or nurse practitioner. Each athlete’s situation is different, though, so sometimes this occurs within days of an injury and other times right before return to play. Typically, if I am covering the game when a concussion occurs, I instruct the athlete to go to the clinic within a few business days, while also relaying to them the red flags that would necessitate going to the emergency room. If I encounter the athlete for the first time several days post concussion and there are no abnormal symptoms, as long as the needed cognitive and physical rest is occurring, I recommend they go to the clinic within the week. I won’t allow an athlete to take part in any contact activities without written clearance from a physician, physician assistant, or nurse practitioner.
Frequently, I spend more time on return to school than return to play. It is tough to balance getting students back in the classroom without exacerbating their symptoms. In these situations, I work with the school to implement the needed accommodations. Sometimes, it can be as simple as the athlete avoiding a noisy hallway or being allowed to put his or her head down during class.
I put a lot of effort into educating teachers, administrators, and athletes on cognitive rest and academic accommodations. The schools appreciate that I think of athletes as students first. But there is still some resistance from coaches and parents in this regard.
Once an athlete is back at school symptom-free, I employ the five-step return to play protocol, usually serving as the link between the provider’s plan of care and the coaches. I recently began using an app to record symptoms to improve communication between concussed athletes and myself since I am not there on a daily basis. I also think the app may provide a better indication of what specific activities cause symptoms, instead of relying on the athlete’s memory.
UPS & DOWNS
As must be obvious, I spend a lot of time in my car. It is not only my second home, but my office. It’s always stocked with snacks, multiple layers of clothing for the various weather during games, a bag of home exercise programs and exercise bands, and of course, athletic training kits. By the end of the fall, it is not a pretty sight!
During the 2013-14 school year, I traveled 12,013 miles for outreach athletic training. When winter hits, my drives are not a lot of fun, and if roads are hazardous, I don’t venture out. Otherwise, I get to see some pretty amazing scenery and quite a bit of wildlife, including antelopes, eagles, hawks, pheasants, and wild turkeys.
Despite the immense amount of driving, I really enjoy my outreach athletic training. I like that it provides many opportunities to serve athletes who otherwise will not have the same access to care. Of course, it is not ideal to be there on such a limited basis, as every school deserves a full-time athletic trainer, but we make do with what we have.
I am not a parent, but I am an aunt, so I try to treat each athlete how I want my nieces or nephew treated. I strive to value each young person I see as an important individual. There is a poem called One Hundred Years From Now by Forest Whitcraft that talks about how what matters most is making a difference in the life of a child. It has prompted an ongoing question for me: Am I making a difference in a positive way?
The heartfelt thank-you notes I have received from athletes affirm that what I do is valuable. I hope I am also a mentor to the student-athletes and an adult they can respect and trust.
SIDEBAR: RUNNING FOR FUN
The smallest school I work with is Ryegate (Mont.) High School, which has nine students. Seven of them currently form the cross country team and will likely be on the track and field squad in the spring, the only sports the school offers.
They are not your typical student-athletes. No one runs a competitive time, and some of them actually do more of a shuffle or speed walk. The team is really about camaraderie and healthy lifestyle.
When the weather is nice, runs often end with water time at the lake. Other days they cross-train by riding bikes. Their coach is teaching them a lot about staying fit and working together.
That doesn’t mean they don’t need an athletic trainer. Running is new to many of the student-athletes, and there are some injuries. Thankfully, the coach stresses that they purchase running shoes for their specific type of feet. But that, of course, only goes so far.
I recently evaluated a sophomore on the team with shin pain that occurred after a practice of running hills. In examining her, I discovered that not only did she overpronate, but she had a tendency to internally rotate at the hip with some valgus of her knee. I started her on calf stretches and hip external rotation exercises.
But most importantly, she left my “office” (the school library) with an understanding of her personal biomechanics and an explanation for several past orthopedic injuries. Her comment was, “Why can’t doctors explain things like this?” and she was excited to go home and tell her mom.
When I left the school, I overheard her relaying everything she learned to her coach, who is also her science teacher. It was a good day.