TRAINING FOR GAME DAY: ESSENTIALS OF BEING A VALUABLE PART OF THE TEAM

Transcription

1 TRAINING FOR GAME DAY: ESSENTIALS OF BEING A VALUABLE PART OF THE TEAM Mark Sytsma, M.D. July 31, 2015 Bronson HealthCare Midwest Sports Medicine 1

2 Disclosure I have no relevant financial relationships or conflicts of interests 2

3 Today s Talks Spine Boarding Protocol Updates (VanHorn) New Standards in Assessment (Baker) CPR Pit Crew Protocol (Farrell) Scenarios and Panel Discussion Practical/Debriefing 2014: Sudden Cardiac Arrest, Concussion, Heat Illness, On Field Management of MSK Injuries 3

4 Objectives Define the members and roles of the individuals involved in sports event coverage. Sport Medicine Team Concept Understand appropriate pre-event/game preparation. Understand a systems-based, team approach to coverage. Know the basics of management of critical sports injuries. 4

5 Active Learning I can teach someone everything about covering sports in less than two minutes. Anonymous Reality Knowledge comes from being on the field and being actively involved in athletic event coverage. We will only scratch the surface today. 5

6 Changing Times Player takes a helmet-helmet hit and sustains a clear concussion. Big Hit Concussion High School Football 2005 Player was taken temporarily out of the game for a period of time until complete resolution of symptoms. Allowed to play that game after time with no symptoms. High School Football 2015 Player taken out for suspected concussion and not to return to game Concussion protocol initiated for gradual return to sport. 6

7 Continuous Learning Our management of injuries is constantly evolving as more research is done. Success for athletes at all levels requires rigorous preparation, training and skill development. The same is required of the sports medicine team. 7

8 Why We Cover Sports Most injuries do not have serious consequences but some do! Hours of preparation, observation and training for a few critical moments. ALWAYS be prepared! 8

9 Why We Cover Sports OUR PRIMARY GOAL The health and wellbeing of our athletes 9

10 Above All Else Protect the athlete More important than the desires of the athlete, coach, parent, etc 10

11 Creating Better Systems Advanced Trauma Life Support (ATLS) Dr. Jim Styner Plane crash in Nebraska Wife killed instantly, he was seriously injured, three children critically injured, one with minor injuries When I can provide better care in the field with limited resources than what my children and I received at the primary care facility, there is something wrong with the system, and the system has to be changed. 11

12 Creating Better Systems To Err is Human First Do No Harm 1999 Institute of Medicine 44k-98k people die each year in hospitals due to medical errors more commonly, errors are caused by faulty systems, processes and conditions Unlabeled medications Surgical Time-Outs 12

13 Sports Medicine Events Success in Sports Medicine Coverage Systems-based approach Needs: Comprehensive action plan for coverage Emergency action plans Defined roles and responsibilities Proper training and practice to execute one s responsibilities Necessary physical resources. 13

14 Defining Roles: Same Team, Different Responsibilities Athletic Trainer EMT/paramedic Physician, team doc Coach(s) Parents Others Assets not Liabilities 14

15 Defining Roles Communication and Preparation is Key Know your team The Dance 15

16 Defining Roles Pre-event Time-Out or The Dance Communicate with team members Trainers, Coaches, Doctors, etc Review Emergency Plan and Resources AED: Check functionality (Wes Leonard) 16

17 Different Events, Different Preparation Football vs Distance Race Contact vs non-contact Equipment Warm Weather vs Cold High School vs Collegiate vs Pro 17

18 18 Game Time

19 Game Time Updates on the Spine Injured Athlete Concussion Heat exhuastion / Heat stroke Specific injuries will not be covered 19

20 Updates on C-Spine Injuries Enormous physical, financial and emotional impact. Much of our current practice in on-field spine management is not driven by clinical scientific evidence. Does spinal immobilization actually protect injured individuals from further injury? Wide variation in practice with respect to spinal injury treatment 20

21 Spine Injured Patient 1-5 million individuals get spinal immobilization each year. Severely Trauamatized Patients 1-3% have spinal fractures % have unstable C-spine injuries 50-70% present with complete spinal injuries Down-sides to C-spine immobilization and radiographic clearance. 21

22 Spine Injured Patients American College of Emergency Physicians Current out-of-hospital management practices of potential spine-injured patients lacks scientific support. Complex Problem Every emergency situation is different Individual circumstances must dictate appropriate actions No such thing as always or never 22

23 New Spine Injury Standards National Association of EMS Physicians and the American College of Surgeons Spinal Immobilization Indicated Blunt trauma and altered/loss of consciousness Spinal pain or tenderness Neurological complaint (e.g. numbness or motor weakness) Anatomic deformity of the spine High-energy MOI Spinal Immobilization Not Necessary No loss/altered consciousness No spine tenderness or anatomic abnormality No neurologic findings or complaints patients with penetrating trauma to the head, neck, or torso and no evidence of spinal injury should not be immobilized on a backboard 23

24 The Spine Injured Athlete 2015: Inter-Association Task Force for Appropriate Care of Spine Injured Athlete 25+ professional associations represented 14 Recommendations on Current Practice May define what we currently hold as Standard of Care. Legal implications? Serves as an excellent template for care of ALL injured athletes 24

25 Appropriate Care of Spine Injured Athlete Recommendation 1: Emergency Action Plan (EAP) Each athletic program should have an EAP developed in conjunction with local EMS Healthcare providers for athletic competition (MDs, EMTs, ATs) should develop an emergency plan and protocol for dealing with such injuries when they occur and rehearse on regular basis 25

26 Appropriate Care of Spine Injured Athlete Recommendation 2: Pre-Event Time Out Sports medicine care teams should conduct a Time Out before athletic events to ensure EAPs are reviewed and plan out the options with the personnel and equipment available for that event. The Dance 26

27 Appropriate Care of Spine Injured Athlete Recommendation 3: Ensure proper assessment and management of injury organized process to quickly obtain information vital to care scene size-up primary survey/resuscitation secondary survey 27

28 Appropriate Care of Spine Injured Athlete scene size-up scene/situation safe and under control MOI/nature of injury c-spine stabilization required number of patients additional EMS assistance needed primary survey/resuscitation assess LOC-Airway,Breathing,Circulation provide immediate basic life support measures as needed quickly make decision regarding transportation secondary survey SAMPLE history (symptoms, allerg, meds, etc ) vital signs secondary assessment head to toe survey 28

29 Appropriate Care of Spine Injured Athlete Neurologic assessment should be performed before and after full-body immobilization Heightened suspicion for catastrophic injury MOI unconscious or altered level of consciousness neurological complaints and/or deficits significant midline spine pain obvious spinal column deformity priaprism respiratory distress neurogenic shock Observe all precautions until spine is cleared 29

30 Appropriate Care of Spine Injured Athlete Recommendation 4: Protective athletic equipment should be removed prior to transport to an emergency facility for patients with a suspected C-Spine injury. Facilitates access to airway and chest, ED evaluation and testing Change from previous practice 30

31 Appropriate Care of Spine Injured Athlete Recommendation 5: Equipment removal should be performed by at least 3 rescuers trained and experienced with equipment removal at the earliest possible time. if fewer than 3 people are present, equipment should be removed at the earliest possible time after enough trained individuals arrive 31

32 Appropriate Care of Spine Injured Athlete Recommendation 6: Athletic protective equipment varies by sport and activity and styles of equipment differ within a sport or activity. Therefore, the sports medicine team must be familiar with the types of equipment specific to the sport and associated techniques for removal of the equipment. 32

33 Facemask Removal Be familiar with all types of equipment utilized by your athletes Utilize quick release facemask clips if possible Riddell Schutt

34 Facemask Removal: Combined Tool Approach Facemask removal tools should be readily available cordless screwdriver cutting device specialty tools for quick release facemask hardware

35 Facemask Removal In the event of respiratory distress or arrest, prior to facemask and/or helmet removal, pocket mask may be positioned through facemask for ventilatory assistance

36 Helmet Removal Rescuer 1 maintains c-spine stabilization Rescuer 2 cuts front of jersey using T technique neck to waist sleeve to sleeve Rescuer 2 opens front of pads to gain access to cervical spine and chest cut front of pads utilize quick release if available Rescuer 2 takes control of c-spine from front: I have c-spine: you can release Rescuer 1 removes helmet Rescuer 1 resumes c-spine control

37 Helmet Removal Rescuer 1 maintains c-spine stabilization Rescuer 2 cuts front of jersey using T technique neck to waist sleeve to sleeve Rescuer 2 opens front of pads to gain access to cervical spine and chest cut front of pads utilize quick release if available Rescuer 2 takes control of c-spine from front: I have c-spine: you can release Rescuer 1 removes helmet Rescuer 1 resumes c-spine control

38 Helmet Removal Rescuer 1 maintains c-spine stabilization Rescuer 2 cuts front of jersey using T technique Rescuer 2 opens front of pads to gain access to cervical spine and chest cut front of pads: utilize quick release if available remove helmet chin strap Rescuer 2 takes control of c-spine from front: I have c-spine: you can release Rescuer 1 removes helmet Rescuer 1 resumes c-spine control

39 Helmet Removal Rescuer 1 maintains c-spine stabilization Rescuer 2 cuts front of jersey using T technique neck to waist sleeve to sleeve Rescuer 2 opens front of pads to gain access to cervical spine and chest cut front of pads utilize quick release if available Rescuer 2 takes control of c-spine from front: I have c-spine: you can release Rescuer 1 removes helmet Rescuer 1 resumes c-spine control

40 Helmet Removal Rescuer 1 maintains c- spine stabilization Rescuer 2 cuts front of jersey Rescuer 2 opens front of pads to gain access to cervical spine and chest Rescuer 2 takes control of c-spine from front Rescuer 1 removes helmet Rescuer 1 resumes c- spine control

41 Shoulder Pad Removal 8 person lift Bi-valve pads Elevated torso technique Flat torso technique May incorporate jersey and pad cutting into log roll or 8-person lift procedures

42 Shoulder Pad Removal 8 person lift cut pads in front and pull off from back when athlete elevated Rescuer 9: pads clear Bi-valve pads Elevated torso technique Flat torso technique

43 Shoulder Pad Removal 8 person lift cut pads in front and pull off from back when athlete elevated Rescuer 9: pads clear Bi-valve pads cut and/or release pads in front and back RIP-KORD system: cut pads in front and release in back Elevated torso technique contraindicated if suspect thoracic or lumbar injury Flat torso technique

44 Shoulder Pad Removal 8 person lift Bi-valve pads Elevated torso technique Side lift technique: Rescuer 1 stabilizes c-spine; Rescuers 2 and 3 elevate torso while Rescuer 4 removes pads contraindicated if suspect thoracic or lumbar injury Ie. For isolated C-spine injuries Flat torso technique

45 8 person lift Shoulder Pad Removal cut pads in front and pull off from back when athlete elevated Rescuer 9: pads clear Bi-valve pads cut and/or release pads in front and back Elevated torso technique contraindicated if suspect thoracic or lumbar injury Flat torso technique Rescuer 2 assumes c-spine stabilization from front and Rescuers 1 and 3 slide pads out axially

46 Shoulder Pad Removal Other considerations: cervical collar rib pads back pad difficulty or inability to cut pads due to materials involved

47 Appropriate Care of Spine Injured Athlete Recommendation 7: A rigid cervical stabilization device should be applied to the spine injured athlete prior to transport properly fitted: rescuer(s) should be trained in fitting relative immobilization in the process to aid in minimizing motion 47

48 Appropriate Care of Spine Injured Athlete Recommendation 8: Spine injured athletes should be transported using a rigid immobilization device concept of spinal immobilization vs. spinal restriction Secure Head to board LAST 48

49 Appropriate Care of Spine Injured Athlete Recommendation 9: Techniques employed to move the spine injured athlete from the field to the transportation vehicle should minimize spine motion. 8 person lift might allow less motion than log roll Immobilize in Neutral spinal alignment 49

50 Appropriate Care of Spine Injured Athlete 8 person lift might allow less motion than log roll Often times there are not eight trained individuals available Log Roll is still an effective technique Maintain neutral alignment 50

51 51 Appropriate Care of Spine Injured Athlete Recommendation 10: A transportation plan must be developed prior to the start of any athletic practice or competition. Recommendation 11: Spine injured athletes should be transported to a hospital that can deliver immediate, definitive care for these types of injuries.

52 Appropriate Care of Spine Injured Athlete Recommendation 12: It is essential that prevention of spine injuries in athletics be a priority and requires collaboration between the medical team, coaching staff, and athletes. Recommendation 13: The medical team must have a strong working knowledge of current research, as well as national and local regulations to ensure up-to-date care is provided to the spine injured athlete. Recommendation 14: It is essential that future research continue to investigate the efficacy of devices used to provide spinal motion restriction 52

53 Appropriate Care of Spine Injured Athlete Important to develop standard guidelines Carefully weigh all factors and make educated decision on what fits best into individual situation Proper planning and preparation: scenario based training Sports medicine team concept Further research and training needed in spinal immobilization and equipment removal techniques. These recommendations will continue to evolve in the future as more research is done. 53

54 54 Concussion

55 Concussion Concussion is injury to the brain that causes temporary loss of normal brain function. Often contact injury but not always May alter behavior, thinking or physical functioning Most occur without loss of consciousness (~90%)

56 Concussion Welker Concussion 56

57 Concussions Recognition of the short-term and longterm consequences of concussion CTE (Chronic Traumatic Encephalopathy) Second Impact Syndrome 57

58 Concussions NCAA looking at requiring schools to have weekly rehearsals of procedures and protocols. Big 10 and SEC will have independent ATCs in replay booth for concussion detection. 58

59 Concussion Assessment Concussions involve, to varying degrees, the following 4 functions of the brain Physical Cognitive Emotional Sleep All Must be assessed

60 Signs & Symptoms Physical Headache Nausea Dizziness Balance problems Visual problems Cognitive Confusion Feeling foggy Feeling slowed down Difficulty concentrating Emotional Irritable Sadness Anger More emotional Nervousness Sleep Drowsiness Sleeps too much Sleeping too little Trouble falling asleep

61 Concussion Assessment Tools Multiple Assessment Tools ImPACT (computerized), BESS, SCAT 3, etc Assessment tools are not fail safe! Our best attempts with the available evidence Clearance to return to sport should be performed by a trained physician. 61

62 Avoid Second Impact Occurs when a second blow to the head occurs before complete resolution of the first concussion Can cause life threatening swelling or bleeding in the brain resulting in permanent disability or death This is preventable DO NOT allow athletes to return to practice or games before they have completely recovered! No system is fool proof! Err on the side of Caution

63 Heat Illness Heat illness is continuum of disease starting with mild heat exhaustion (fluid volume loss disorder) and ending with severe heat stroke (end organ damage from thermal stress). Hyperthermia- core temperature greater than 98.6 F. 63

64 Dehydration Usually, the first manifestation on the heat illness continuum Signs/symptoms: Muscle cramps Thirst Fatigue Sweating Facial flushing 64

65 Heat Exhaustion vs. Heat Stroke Heat Exhaustion Mild to moderate dehydration Core temperature 98.7 to degrees Profuse sweating Signs: Thirst, nausea, vomiting, flushing, anxiety, hypotension, decreased urine output, tachycardia Symptoms: anorexia, dizziness, fatigue, headache, nausea, visual changes, weakness Heat Stroke Severe dehydration Core temperature over 104 degrees F Signs: DRY SKIN/NO SWEATING, dizziness, syncope, ataxia, confusion, unconsciousness, shock, Liver and Kidney failure, rhabdomyolysis, pulmonary edema, seizure, DIC, cardiac arrhythmia Symptoms: anorexia, dizziness, fatigue, headache, nausea, visual changes, weakness

66 Management Heat Cramping/ Dehydration Remove from play Hydrate Cool the athlete Heat exhaustion/stroke Cool immediately Water immersion Cool 1 degree F/3 min Transport to hospital once cooled of immediately if no resources to cool 66

67 It is preventable Heat Illness Check the weather and adjust appropriately Flexible practice times Acclimitization Understand early signs and risk factors Tracking water deficits 67

68 MHSAA Policy (adopted March of 2013) 1. Measure temp/humidity at site of activity 30 minutes prior and 60 minutes after start of activity. Record readings and maintain in files of school administrator. Sling psychrometer is recommended. 2. Heat index below 95 degrees- All sports provide ample water, water breaks q 30 minutes for 10 minutes, ice towels for cooling, monitor athletes closely 3. Heat index degrees- All sports provide ample water, water breaks q 30 minutes for 10 minutes, ice towels for cooling, monitor athletes closely. CONTACT Sports- remove equipment (helmets) while not in drills. Consider reduction in time of practice, move practice later in day. Recheck temp/humidity q 30 minutes.

69 MHSAA Policy (adopted March of 2013) 4. Heat index degrees- All sports provide ample water, MANDATORY water breaks q 30 minutes for 10 minutes, ice towels for cooling, monitor athletes closely, allow to change to dry uniforms. CONTACT Sports- remove equipment not necessary for safety, if necessary suspend activity. Reduction in time of outside activity, move practice later in day. Recheck temp/humidity q 30 minutes. 5. Heat index >104 degrees STOP all outside activity in practice/play and all indoor activity if air conditioning is unavailable.

70 After The Game/Event Communicate with other sports medicine teams to assure needs are addressed Host team responsibility Manage less emergent injuries Debriefing on injuries and injury management protocols 70

71 Game Time Summary Systematic Approach: Comprehensive action plan for coverage Emergency action plans Defined roles and responsibilities Proper training and practice to execute one s responsibilities Necessary physical resources. 71

72 Boston Marathon April 15, :49PM Officials Swept Area Twice for Bombs That Day 2 pressure cooker bombs detonated 281 injured, 3 died at scene 127 sent to trauma centers 54 underwent surgical intervention 12 amputations 6 trauma centers involved primarily Computerized trauma triage system 72

73 Lessons from the Bombing Adequate preparation (EAPs, resources, etc ) Rapid logistical response Methodological multidisciplinary care Short transport times Good Fortune Gates JD, et al. The initial response to the Boston marathon bombing: lessons learned to prepare for the next disaster. Ann Surg Dec 73

74 Prevention Proper training of athletes Structured Training and Performance Training Hydration and nutrition of athletes When in doubt, hold the athlete out 74

75 Prevention STOP Campaign Resources for coaches, athletes, parents, medical providers Pitch Smart 75

76 Bronson Sports Medicine Multidisciplinary Approach The whole athlete Team and club relationships High school, colleges, professional Sport Medicine Team Physicians, athletic trainers, performance trainers Prevention Programs, Community Outreach, Education, and Support 76

77 We Are Here to Help Mark Sytsma, MD Jeff Willson, ATC Scott Sell, ATC 77

78 Credits Dr. Jim VanHuysen Dr. Robert Baker Heather Sjoquist, ATC Ron Courson, ATC 78

79 79 Questions