Fig. 29.1
Daily report on injury form. The consensus options in each category are included. Adapted with permission [8]
Fig. 29.2
Daily report on illnesses form. The consensus options in each category are included. Adapted with permission [8]
Prior to competition all athletes should receive medical clearance from their primary care, sports, or team physician. Consideration should be made for requiring and collecting the medical clearance forms and ensuring that they have the adaptive athlete’s pertinent medical history. This will help if an athlete is unresponsive. In addition it will greatly aid if classification is required to place athletes in appropriate ability groups. Protection of the athlete’s health information is paramount, and processes should be in place to ensure no violations occur. Competitors should be required to sign a waiver acknowledging the physical requirements needed for the event(s) that they are competing of their own free will, that there is a risk of injury, and that the event organizers are not responsible for any injury or illness which may result. The waivers can also state the level of medical support that will be available and serve as an informed consent. We recommend waivers be reviewed by the organizer’s legal counsel prior to introduction to the athletes. Although these waivers do not guarantee avoidance of a malpractice claim, they do provide a layer of protection. The waivers should also be accompanied by an education packet of the physical demands needed to successfully complete the activities in addition to suggested training strategies to accomplish the requirements. As mentioned earlier a discussion should occur at the planning stage if some applicants will be disqualified from competing. In general though for the spirit of the games in adaptive sports, the event organizers should attempt to make every accommodation possible for an athlete to compete as long it is safe for all competitors and does not violate the rules of the competition.
Liability/Medical Malpractice
The medical director must know who is providing the malpractice insurance coverage and the provisions of the coverage for the medical staff. Did the event organizers purchase liability insurance that would specifically cover health-care providers, or does it just cover the liability for the event planning organization? It is incorrect to assume the Good Samaritan laws will provide adequate liability alone and in some cases may be deemed non-applicable to the health-care providers. In general Good Samaritan laws are designed to protect health-care providers who, while not in any official medical capacity, render aid within their scope of practice (i.e., while driving they witness a car accident and stop to render assistance). Good Samaritan laws are state specific, nuanced, and do not protect against gross negligence or misconduct and provide no financial support for legal defense. These laws do not apply while volunteering to support an event and definitely do not apply if you are compensated in any way. Therefore, if the health-care provider is specifically providing official medical coverage (whether compensated or not), they need to seek alternate liability coverage options.
On the other hand, the Federal Volunteer Protection Act (VPA) does provide a degree of coverage according to the Association of State And Territorial Health Officials; the Federal VPA “provides protection to nonprofit organizations’ and governmental entities’ volunteers for harm caused by their acts or omissions on behalf of the organization or entity. The act does not require that an emergency declaration be in place for its protections to apply.” [10] As in the Good Samaritan law, any compensation negates the act, and the Federal VPA does not protect the volunteer from legal action taking from the event organizers. The Federal VPA applies to:
It does not apply to:
Uncompensated volunteers
Volunteers properly licensed, certified, or authorized by state law
Volunteers of nonprofit organizations or governmental entities
Acts within a volunteer’s scope of responsibility
Acts of ordinary negligence
Willful or criminal misconduct, gross negligence, reckless misconduct, or a conscious, flagrant indifference to the rights or safety of the individual(s) harmed by the volunteer
Harm caused by operating a motor vehicle, vessel, aircraft, or other vehicle for which the state requires its operator to possess an operator’s license or maintain insurance
Volunteers for businesses
The organization or entity utilizing the volunteer
There are also State VPAs which may or may not afford greater protection. All volunteer medical providers are encouraged to check with their malpractice insurer for further information.
Whether you are even allowed to provide care as a team/event physician if the competition is in a venue other than where you are licensed depends on the state. Table 29.1 lists the state licensing boards that would and would not allow out-of-state licensed team physicians to care for athletes in their state [11]. There is an ongoing effort by sports medicine organizations such as the American Medical Society of Sports Medicine (AMSSM) to enact a policy/statute which provides legal provisions allowing sports medicine medical staff traveling with their teams to another state to provide medical services to their team. Rules change and state licensing boards should be contacted for the latest information for proper planning. Military physicians must be cognizant that they are only legally protected while performing their function in an official capacity to eligible beneficiaries. They also must adhere to the privileging requirements of the local military treatment facility in the area where they may be practicing. They are not covered by the military when providing volunteer services to a civilian cohort unless they are doing so as part of their military duty.
Table 29.1
State medical licensing board response to “Can the traveling physician practice in your state?” [11]
No | Yes |
|---|---|
AK, AL, AZ, DC, GA, FL, HI, ID, IL, KS, LA, MA, MD, ME, MI, MO NE, NJ, NM, ND, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, VT, WI, WV | AR, CA, CO, CT, DE, IA, IN, KY, MN, MS, MT, NH, NC, UT, VA, WA, WY |
Event Coverage
The medical support logistical footprint is greatly influenced by the venue and events being covered. The two constructs for medical support are distributed care and consolidated care. In general a combination of the two is ideal if feasible with space, equipment, and personnel. The majority of resources should be concentrated somewhere near the finish line or in a central location if multiple activities are occurring in different venues. Road races should generally have some sort of first aid or checkpoint at least every 3 km [12]. There is debate about what level of care should be at these stations. The final decision will be dictated by the type of event, distance/time it would take to get to the main medical tent or definitive care, and the number of trained personnel. If travel time is greater than 10 min to the main medical tent or emergency facility, then at a minimum Basic Life Support (BLS) supplies with an automated external defibrillator (AED) and epinephrine for anaphylaxis should be available. A reliable communication method as discussed above is paramount. Another option is a roving aid station that follows competitors. Each venue and event is unique, but as stated earlier, prior planning will ensure services are available when required.
Personnel
Medical coverage organizers must estimate personnel and medical equipment which will be required to support the entire duration of the competition. This is best accomplished by reviewing data from previous iterations of the same event. Should these reports not be available or if the activity has changed substantially, then reviewing historical norms of similar events can guide the estimate. General guidelines suggest that approximately 10% of competitors may require medical care [12]. This estimate can differ though depending on the types of activity. Cycling and triathlons averaged 5%, while multisport and obstacle course events averaged 30% [13, 14]. It is suggested that for every 1000 participants there should be 20 providers with 5–8 being physicians. Nursing and medic personnel should make up at least 50%–75% of the staffing [13]. With very large multiday events, support from radiology and pharmacy may be considered. Depending on the care being offered (i.e., multiday events where ongoing care is offered), a physical therapist or athletic trainer can be considered as well. A suggested distribution is 80% of assets around the finish line or main medical tent, with 10% roving and 10% distributed along aid stations [12]. These estimates do not include administrative personnel. For every 20 health-care providers, 5–10 lay administrative personnel should be available. They can help with crowd control, record keeping, and some patient transport [13].
Many athletes and teams will travel with their own medical support. The medical director should confer with the athlete/team medical support to ensure an understanding of what role they will play. In multiday events at a minimum, there should be a medic or nurse manning the tent 24 hours a day to triage with a physician on call should immediate care be warranted. As mentioned previously, high-risk events will require prior coordination with local medical authorities in the case of a mass casualty that overwhelms the capabilities of event planning assets.
Medical Supplies
To properly prepare for medical coverage of a multisport event, organizers must predict as precisely as possible the medical equipment which will be required for support. What to bring and how much depends on the actual event, with multiday events requiring more logistical support. Proximity to local health-care resources and the level of care that is predetermined are other additional factors that should be integrated into the planning process. A good conceptual planning tool is an organ system approach such as in Table 29.2. The list is not all inclusive nor is each item mandatory. Instead, within each category both equipment and medications should be considered as well as approximate amounts based on the expected injuries/illnesses, casualty estimates, and resupply plan mentioned previously. One must not forget about infection control to include personal protection, patients, and equipment.
Table 29.2
Medical equipment and medication
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