CHAPTER KEY WORDS

• Emergency action plan
  
• Emergency team personnel
  
• Pregame and pre-event medical time out
  
• Standard operating procedures
  
• Specific venue locations

CHAPTER SCENARIO

A jury in a Court of Common Pleas awarded a 14-year-old $1.7 million in damages against 2 local youth baseball athletic associations.

The youth male baseball player, then age 11, was hit by a foul ball while in the dugout during a game played at the community park baseball field. The boy was badly injured, and medical testimony was presented that there would be long-term consequences, as well as pain and suffering, from the injury.

The attorney for the boy said that the defendants were responsible for the injury because the dugout was not properly protected by a fence to prevent foul balls from entering that area. There was evidence that such fences are required by the Little League’s emergency action plans (EAPs) and standard operating procedures (SOPs) and are customary at all Little League Inc. baseball fields.

Right after the incident, the father took his son to a local hospital, and the boy was then rushed to Children’s Hospital, where he underwent brain surgery. As a result of his injuries, the player sustained a fractured skull, brain shift, and bleeding on his brain, as well as severe changes in behavior, mood, and impulse control.

“He woke up a different person,” his father said. “His whole personality changed.”

The boy changed schools and now is accompanied by special education teachers in his classes. According to his father, he has struggled with his studies and has pain every day.

During research into the lawsuit, investigators discovered that another child, who was in the same dugout, had been struck in the chest by a foul ball 1 year earlier. However, the child was wearing a chest protector and was not injured.

“They knew it, and nobody did anything,” the boy’s father said. “They let it go.”

According to Little League Inc. safety policies, all dugouts need to be fenced and screened, and the attorney indicated that the dugout at this particular baseball field did not meet the organization’s standards.

SCENARIO RESOLUTION

One week after the young player’s injury, the rest of the fencing was added to the dugout, and 1 month after that, venue-specific EAPs with SOPs were developed and approved by the local township parks and recreation department and the youth baseball league.

Over the past 2 decades, many research projects involving athletics at all levels found that almost one-third of athletes competing were injured in a way that required medical attention.1 The National Athletic Trainers’ Association (NATA) position statement recommends that each organization and/or institution sponsoring athletic activities and events should design and implement a written emergency plan.² The EAPs and SOPs need to be designed with the help of organizational and/or institutional personnel in consultation with local emergency medical services (EMS) and emergency care facilities.

The EAP needs to be implemented for the safety of all athletic personnel, including athletes, coaches, and officials. It should be concise, yet detailed enough to facilitate prompt and appropriate action. The development of an EAP and proper use of this plan can often make the difference in the outcome of an injury situation. All components of an EAP are connected, and they must all be considered to ensure a complete and favorable outcome in a potentially dangerous situation. When the importance of the EAP is realized and the plan has been designed, it must be implemented through documentation of the plan, education of those involved, and frequent rehearsal of the plan itself.²

The EAP must provide a clear explanation of how it is going to work, allowing continuity among all members of the athletic training staff and other emergency team personnel. It is important to have a separate plan for different athletic venues and for practices versus games. Emergency medical team personnel, such as team physicians, may not be present at all athletic events, and this should be considered during development of the EAP. In addition, the specific location and type of equipment required may vary among the sports teams and venues. For example, outdoor sports with a high risk of heat illness exposure may require a large tub or wading pool for emergency cooling of athletes at risk of heat stroke. This equipment would not be required for indoor sports.

It is important to educate all medical team personnel regarding the EAP and its contents. All team personnel should be familiar with the EMS that provide coverage to the venues. Each emergency team member, as well as the athletic organization administrators, should have a written copy of the EAP that provides complete documentation of their roles and responsibilities in all emergency situations. Copies of the EAP specific to each venue should be posted by a prominent marked position at that venue.²

All members of the medical team need to practice the EAP. This provides the team members with a chance to maintain their emergency skills at a high level of competency. It also provides the opportunity for athletic trainers and other emergency personnel to communicate regarding specific procedures in their respective areas. The EAP rehearsal can be accomplished via meetings held several times throughout the year. One suggestion is to rehearse prior to the preseason for high-risk sports such as football in the fall, ice hockey in the winter, and lacrosse in the spring. Updates should be addressed as needed throughout the year, as venues, emergency medical procedures, and emergency team personnel may change at any time.

There is a legal need and duty for emergency team personnel to develop EAPs to ensure that the highest quality of care is provided to all physically active sports participants. The emergency team, including athletic trainers, is measured in part by the standards of care provided to athletes, which is 1 reason it is important to have a written document.3,4 The NATA has indicated that a well-organized and well-written EAP document that is regularly rehearsed is essential for all athletic organizations and sports medicine programs.^2,5,6

The athletic organization administrators and emergency medical team personnel must anticipate that a possible medical situation may occur during any athletic activity. Injuries to the head, spine, and limbs are possible in both practice and competition. A duty exists on the part of the athletic organization and the emergency team to provide proper care for any medical conditions that result from athletic participation. Although it is not common in athletic activity, the athletic trainers and the rest of the emergency team must always be prepared for any type of life- or limb-threatening injury. Failure to have an EAP in place and to rehearse it regularly may result in inefficient or inadequate care, which could lead to charges of negligence against the athletic organization administration and emergency team personnel.^2,7

Several legal cases have supported the need for written EAPs. The most prominent is Kleinknecht vs Gettysburg College, which went to court in 1993.⁸ As part of the decision, the Court stated that Gettysburg College owed a duty to all recruited athletes and that the college must provide “prompt and adequate emergency services while athletes were engaged in school-sponsored intercollegiate athletic activities.”⁸ The same court also ruled that reasonable measures must be ensured and in place to provide adequate and prompt treatment in any emergency situation.⁸ It can be concluded from this ruling that planning is critical to ensure that athletes receive proper emergency care, which further reinforces the need for a written EAP as a requirement for all athletic organizations.^2,8

It is also important to involve athletic organization administrators, sport coaches, and sports medicine staff in the development process of the EAP (Figure 1-1). The EAP needs to be updated annually by all involved emergency team personnel. All revisions to the EAP must be approved by members at all levels of the athletic organization, as well as emergency team members, including local EMS.⁷

Emergency Team Personnel

The implementation of an EAP cannot take place without the formation of an emergency team. The emergency team personnel consists of members of the sports medicine staff, including the certified athletic trainer and the team physician. The sports medicine staff is responsible for the formation of the EAP for the entire athletic organization.⁹ When a potential situation occurs, the emergency team can vary depending on who is at the scene. The emergency team can include certified athletic trainers, team physicians, local EMS, athletic training students, team coaches, equipment managers, and school nurses. Any member of the emergency team can act as a first responder—a person who has been trained to provide emergency care before EMS personnel arrives on scene.^2,10

All personnel within the emergency team should be required to be certified in cardiopulmonary resuscitation (CPR), automatic external defibrillation (AED), and prevention of disease transmission (eg, Occupational Safety and Health Administration blood-borne pathogens). An extensive EAP review should be required for all emergency team personnel associated with athletic practices and all events and competitions.¹¹

The roles of the personnel of the emergency team will vary depending on how many people are on the team, the specific venue being used, and the preferences of the certified athletic trainer, who is usually in charge of the design and implementation of the EAP. Roles of the team personnel should include immediate care of the athlete/patient, emergency equipment retrieval, communication to EMS, and proper transport to the emergency care facility.⁹

When assembling the emergency team, it is important to allow each member of the team to adapt to all emergency role situations that may occur. It may be a good idea to have more than 1 individual assigned to each of the designated roles. This allows the emergency team to function without delay in an event where some personnel may not always be present.

Emergency Equipment

All appropriate emergency equipment and supplies must be on hand at all athletic practices and events. All assigned emergency team personnel should be aware of the location and function of all emergency equipment and supplies. Ensure that all emergency equipment can be properly inventoried and maintained on an annual basis and stored in a secure storage area for safekeeping by the athletic training staff.¹²

All school and organization members must recognize the importance of the availability of AEDs (Figure 1-2) as indicated by guidelines set forth by the American Heart Association and the National Safety Council.^11,13 These guidelines indicate that early defibrillation is considered a critical component of basic life support. It is also important to use proper airway techniques for resuscitation when necessary. Emergency team personnel should be educated in the proper use of AEDs and airway adjuncts before being allowed to use them.^14,15

All emergency equipment must be in good operating condition and should be checked on a regular basis. An emergency situation is not the time to find out that a piece of emergency equipment is missing or is not working. Each emergency team member must be trained in advance on how to use all first aid equipment and supplies. Finally, all emergency team personnel should regularly practice with all safety equipment so there is no delay in the effective use of the equipment during an actual emergency.

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