EMERGENCY RESPONSE ISSUES IN SPORT

John Boulay B.Sc., CAT(C), EMT-P, D.O.(Q)Certified Athletic Therapist, Paramedic, Osteopath

First Responder/EMR Instructor-Trainer

OTTAWA March 25th,2011

EMERGENCY RESPONSE ISSUES IN SPORT

1. Remain current2. Level of training 3. Skill sets4. Airway management5. Sports equipment removal6. Away venue7. Home venue8. Mock-up / simulations

1. REMAIN CURRENT• Practice and standards are always improving.• New approaches to old problems are being

developed.• Change in major standards every 5 years and

we just entered the transition period ILCOR, PHTLS etc.

Primary Survey ILCOR OCTOBER 2010

UEMS/911 CABdDEFIB

Secondary Survey Head to toe / PMSCx 4 / Vital Signs

D E F G Disability (head / spine) Epidermis Fracture General

Research in Emergency Response

• Research on decades old skills/myths in progress.

• New possibilities exist with advances in electronic monitoring. Movement that was difficult to measure in the past now possible.

• Training and knowledge of performance a useful future training tool for rescuers.

Position Papers USA vs CANADA

• Standards vary and USA positions papers don’t always reflect the Canadian realities.

• For years it has been mentioned to keep the equipment on until arrival at the ER. Recently modified if “affects resuscitation efforts”

• Why wait until then to orderly remove the equipment on-site by trained personnel?

• Most ER trauma teams don’t have personnel with expertise in sports equipment extrication.

2. LEVEL OF TRAINING• Since 2001 the basic standard has become First Responder (FR)• Most groups now employ some type of FR training and similar

skill sets.• SKILL SET include: CPR, AED, airway adjuncts, ventilation, O2 admin, suction, bleeding/wounds, fracture/spinal management, medical emergencies, anaphylaxis, etc.• FR now required: CAT(C): exam/games applications SPC, Sport Chiro, Sport Masso: membership• EMR: within 5 years may become the basic standard of care.

Standards Consensus

• Pre-hospital consensus among groups, regions difficult

• Important to follow local guidelines and be aware of variances in other regions.• When a visitor, use local approach, as long as it is safe and is sports specific.• Need to know variations, what works and

what doesn’t.

EMS vs Sports Med Intervention

• If time, training ,equipment and staff permit...don’t delay immobilization and packaging.

• Spinal transfer and immobilization is best performed by a skilled on-site sport med team than a pair of paramedics.

• MSK injuries are much better managed by skilled sport med team members than paramedics with little training in this area

• On-field responders should stay within comfort level with respect to training, available equipment and resources.

3. SKILL SETS eg: SPINAL MANAGEMENT Head stabilization: Head Hold (head squeeze), Trap Hold (trap squeeze)Cervical Collar- sizing/application: supine, standing, seated, four-point Supine Emergency Log Roll - Emerg LR-1, Emerg LR-2 (vomit)Prone Emergency Log Roll - Emerg LR-1, Emerg LR-2 (no pulse/breathing)Supine Lift & Slide- technique of choice, better than log roll: L&S-8, L&S-6, L&S-4 Supine Log Roll - more movement than L&S, requires fewer rescuers: LR-5, LR-4, LR-2 Supine Straddle-Lift - applicable in tight spaces, uneven surfaces: SL-5, SL-4Prone Log Roll-rescuers on spine board lunge back & pull patient onto board: PR-4Standing Take Down-collar, patient brought down on board,2 rescuers,1 spotterSeated Take Down - collar first, patient brought down on board with 3-5 rescuers Four-Point Take Down - collar first, patient brought down with 3 rescuers 4-point lateral/roll, 4-point prone/rollStrapping: (PHTLS) Torso-2 straps cross, ASIS-1 strap horz., Mid-Femur-1 strap horz., Leg/feet-Fig. 8 (ITLS) Torso-2 straps cross, Pelvis-2 straps cross, Legs-1 strap horz. Repositioning on board: (PHTLS) lateral then vertical, (ITLS) V-slide

8-Person LIFT - SUPINE

1 Responder at head, 6 persons at sides, 1 person at board (caudal)“1-2-3 Lift”(6 inches), “STOP”, “SLIDE BOARD”, “STOP”, “1-2-3 DOWN”

Head Stabilization

• Head Hold (squeeze) VS. Trap Hold• A topic of discussion over past 25 years.• Head Hold: best hold during transfers• Trap Hold: best hold for agitated spinal victim

• Ref: New original research: Clin Jour Sport Med

METHODS

Head Squeeze Trap Squeeze

Best hold duringTransfers and lifts

Best hold to stabilize Agitated victim

Causes less movementthan log roll, requires6-8 rescuers

Less effective thanL&S, can be performedby 2 rescuers (ambulance)

4. AIRWAY MANAGEMENT• Head-Tilt Chin-lift (non-spinal)• Trauma Jaw thrust (spinal suspect)• Trauma Chin lift (temporary access, spinal suspect)

• Rescue Airway (King LT) for sports physicians• Provides definitive blind intubation in the field.• One of most important roles of sports med doc on the

field: provide/maintain definitive/patent airway.• Certain risk sports also need doc to be able to manage surgical airway.

Airway management approach

• Clinical circumstances• Skill of responders• Physician/Available resources

• *As per CMPA, physicians role on the field of play is as a “FIRST RESPONDER”

Extraglottic Rescue Airway Devices

• Supraglottic airway devices– LMA– ILMA

• Infraglottic airway devices– Combitube– King LT

Supraglottic airway devices

LMA ILMA

Infraglottic airway devices

Combitube placement King LT placement

Combitube and King LT• Seal Larynx between esophageal and oropharynx balloon• Combitube has 2 pilot balloons; King LT has 1• Success rate: 98-100%

• Combitube not for children <4 feet tall• King LT comes in children sizes• No optimum protection against aspiration• OK to use in upper GI and upper airway hemorrhage, and in facial burns

KING LT IS “RESCUE” AIRWAY OF CHOICEFOR SPORT PHYSICIANS IN THE FIELD

5. SPORTS EQUIPMENT REMOVAL

• Trained/rehearsed in extrication of equipment within 30 days of start of season.

• Equipment should be removed sooner than later depending on available resources.

• If only one trained rescuer, provide basic life support as required, consider removal upon

arrival of paramedic team

The faceguard (facemask) should always be removed first for a suspected spinal.

Research has shown there is less movement of the head/neck during helmet removal when the facemask is removed first.

This is especially true with obese players (ie: linemen) because their helmets tend to fit

so tight (skin folds and fat fit all parts of the helmet).

Long face masks also present a challenge with pads still in place and helmet rotation needed to clear face is limited.

6. AWAY VENUE• At mercy of local emergency response• eg: NHL practice venue model (since 2009) ensures a fully equipped trauma kit is available to

visiting teams for their practices.• eg: Francophone games in Madagascar, there was

no real EMS or host medical at venues. During the marathon, Canada ended covering for all teams along the route.

• Never rely exclusively on host medical to provide all of your needs.

SIDEWALK HAZARDS IN THEATHLETE’S VILLAGER

COVERING THE MARATHON ROUTE

OPENING CERMONIESOF THE GAMESINCLUDED RELEASE OF “ZEBU” INTO THE CROWD.

FRANCOPHONE GAMES Madagascar

PART OF THE “GAMES MISSION”AND LEGACY WAS TO TRAINHOST MEDICAL IN EVENT COVERAGESKILLS.

CANADA ALSO LEFT BEHINDDEVELOPMENT-FUNDED MEDICAL EQUIPMENTINCLUDING OUR FOUR-WHEELDRIVE AMBULANCE WHICHWE HAD SHIPPED OVER.

7. HOME VENUE• Many advantages of home based games

Example: Vancouver 2010• Globally excellent medical care and access.• But as in every games, some issues with Field of Play access.• There were also some issues with certain pre-hospital skills applied to field of

play.• A video entitled “Protect the cord” was being circulated as the skill set for the

2010 games. Unfortunately it was primarily aquatic based and not appropriate for winter games .

• There was also para-medical coverage and safety issues at the Whistler sliding center as far as a year prior the pre-opening ceremonies fatality.

• There is no blame intended, as this is mentioned to illustrate the challenges that are present at every event, even one as great as the 2010 games.

MMUWorld Class Care

8. MOCK-UP / SIMULATIONS

Need to constantly strive to improve our preparation & enhance our interventions.

KEEP THEM SAFE!