The Team Physician

Introduction: the team physician

The medical care of a team or squad of athletes is an integral part of the role of the sports medicine specialist, and potentially one of the most rewarding aspects of sports medicine practice.

The specifics of the team physician role will depend on a variety of issues including the sport involved, the nature of the event, e.g. single sport or multi-sport, and the level of competition or ability of the athletes. There are, however, a number of general principles that are relevant to team medical support in general, and some special circumstances.

The medical kit bag

The medical kit bag is of central importance in enabling a clinician to practice. The equipment that you take to an event will depend on a number of factors.

Experience of practitioner

Carry equipment that you are competent to use. If covering a sport that might require a particular piece of equipment then seek appropriate training before agreeing to cover that event. If your level of knowledge and experience is not commensurate with that required to provide a duty of care for those you are looking after, then you should not be there, no matter how attractive the opportunity.

Medical risk assessment

A vital part of team coverage is medical risk assessment. This means identifying what problems you are likely to encounter, what facilities will be at your disposal to deal with such events, and what additional equipment will you need to provide or arrange to have provided. A number of issues will govern the medical risk associated with a particular event.

Sport

Different sports clearly carry different injury profiles, e.g. the high risk of contact trauma associated with rugby union compared with the low risk associated with tennis. You must have an appreciation of the injury profile of the sport to be able to adequately plan. It would, for example, be indefensible if you could not adequately immobilize the cervical spine when covering a rugby match, whereas serious cervical injury would be highly unlikely on a tennis court. That said there are core skills which all doctors covering sport must maintain, and emergency medical skills including the management of cervical injury are such skills no matter how unlikely such an injury.

Venue or event

The venue will influence the equipment that you carry. The equipment you will personally need to arrange, for example, to provide medical cover at rugby international at Twickenham will be very different from that required to cover a game at a local rugby club. Similarly consider the role of the medical officers for the London marathon, run over the same distance as another on the foothills of Mount Everest. The following list, although not exhaustive, covers many of the important factors:

Will you be a single handed practitioner or part of a team of clinicians? If part of a team what is their experience, what equipment are they likely to bring?
What medical equipment will be provided by the venue (e.g. is there a fully equipped medical room)?
Emergency medical support (will there be a paramedic ambulance on site) and what equipment will they have at their disposal?
Where will you be situated in relation to the field of play and what access to the field of play do you have?
Where are the nearest emergency care/hospital facilities?
What is the transfer time to these facilities and how might that change on the day of competition?
Environment and climate considerations.

The team you are covering

Most athletes are by definition healthy, however, they may have medical conditions, e.g. diabetes, asthma, or disabilities that will influence what equipment you require. Furthermore, you will almost certainly be responsible for the health of those individuals supporting the athletes, e.g. performance directors, coaches, medical and paramedical staff. In some circumstances you may even have responsibility for family members including children. Support staff may have a variety of chronic illnesses and medical requirements and you should be prepared. If you are travelling with a team with whom you don’t usually work it is useful to send out a questionnaire prior to departure requesting key current and past medical history, medications, and allergies. Even if you do work regularly with athletes there may be athletes, support staff, or additional party members to with whom you are unfamiliar.

Touchline kit bag

The key to a basic first aid kit is to only put in what you know how to use. It should be hands-free, carried on the shoulder or waist and should be clean, compact, and secure.

Suggested contents will depend on the sport you are covering, but might include:

Squirty water bottle or ampoule: this allows pressure to be exerted when irrigating wounds. Pressurized canisters are commercially available.
Gauze swabs.
Disposable gloves.
Tape.
Scissors, forceps, tweezers.
Stethoscope, BP cuff, torch/opthalmoscope, tongue depressor.
Assorted plasters, sterile wound dressings and bandages.
Antiseptic spray and wound congealer.
Insect sting/bite relief spray.
Analgesia, antihistamines, buccal anti-emetic.
Emergency drugs, e.g. adrenalin (epipen), ventolin, GTN, glucose, aspirin.
Pocket facemask, oral and nasopharyngeal airway, petroleum jelly.
Pen and paper or copies of a suitable incident report form.
Clinical waste bag.
Telephone.

Basic medical equipment

In addition to a touchline carry on bag there is a basic level of equipment to which every doctor covering sport should have immediate access and, of course, be able to use. The following list is included as a guide.

Stethoscope.
Portable sphygmomanometer.
Oto/opthalmoscope/spare batteries.
Scissors.
Nail clippers.
Tongue depressors.
Thermometer.
Oropharyngeal airways (e.g. Guedel sizes 2, 3, 4).
Nasopharyngeal airways (6-8mm).
Petroleum gel.
Pocket mask with mouthpiece and O₂ inlet (e.g. Laerdal).
Alcohol wipes.
Antimicrobial soap/gel.
Cleaning fluid (e.g. chlorhexidine, betadine sachets).
Semipermeable dressing (e.g. Tegaderm) various sizes.
Low adherence dressing (e.g. Mepore) various sizes.
Sterile gauze swabs and cotton wool.
Tubular bandage (e.g. Tubigrip).
Elastic/adhesive bandage (e.g. crepe).
Cohesive bandage.
Permeable adhesive tape.
Blister pack.
Sterile and non-sterile gloves.
Adhesive strips (e.g. Steri-strip).
Tissue adhesive (e.g. 2-octyl cyanoacrylates).
Suture kit.
Scalpel and blades.
Razor.
Sharps bin.
Assorted needles and syringes.
Tourniquet.
Blood and specimen bottles.
Peak flow meter and disposable mouthpieces.
Assorted cannulae and giving set.
500ml bag of dextrose/saline (emergency use only).
Adjustable hard collar.
Safety pins.
Tape measure.
Urinalysis testing strips (e.g. clinitest).
Eye kit.
Glucose testing meter and test strips.
BNF or access to BNF online.

Don’t forget the obvious non-medical items, e.g. pen, paper, mobile telephone, and useful contact numbers. A driving license is often helpful.

Drugs and medications

If providing medical support to a large team or squad competing internationally you may need an extensive drug list to cover most medical situations. Irrespective of what drugs you have available at a main base there are basic drugs/medication that you should aim to have easy access to. This list is only a guide as it will be influenced by the medical history of your team members.

Emergency management

Epinephrine (adrenaline) (1/1000) 1mg in 1mL pre-filled syringe and Epipen.
Parenteral antihistamine, e.g. chlorpheniramine (10mg/mL).
Hydrocortisone IV 100mg vial.
Oral steroid.
Concentrated (40%) glucose or dextrose gel.
Furosemide (IV and oral) depends on circumstances.
Midazolam 1mg/mL as 50mL vial (optional).
Parenteral opiate analgesia (e.g. pethidine 25mg/1mL amp or morphine) depends on circumstances.
Naloxone (optional, if carrying opiate analgesia essential).
Nitrolingual spray.
Aspirin oral.

General

Anaesthetic, e.g. lidocaine, bupivacaine.
Intra-articular steroid, e.g. triamcinolone, methylprednisolone.
Sterile water ampoules for injections/irrigation.
Antihistamine (oral and topical).

Analgesia

Paracetamol.
Compound analgesic (e.g. co-codamol).
Parenteral analgesia (e.g. IM diclofenac).
Oral NSAID, e.g. ibuprofen, diclofenac.
Topical NSAID, e.g. diclofenac patch and gel.
Aspirin 75mg dispersible.

Antibiotics

Penicillin (IV and oral).
Non-penicillin broad spectrum IV antibiotics.
Other oral antibiotics, e.g. azithromycin, augmentin, amoxycillin. metronidazole, ciprofloxacin, acyclovir.
Topical anti-bacterial and anti-fungals.
Antibiotic drops suitable for ocular and aural use.

Gastrointestinal

Antacid, e.g. gaviscon.
PPI, e.g. omeprazole.
Diarrheoa, e.g. loperamide.
Constipation, e.g. senna.
Bowel spasm agent, e.g. mebeverine.
Rehydration sachets, e.g. diarrolyte.
Anti-emetic, e.g. prochlorperazine, buccal and IV/IM.

Respiratory and ear, nose, and throat/eyes

Beta-2 agonist/steroid inhaler for oral/nasal use.
Throat lozenge (e.g. merocaine, strepsil).
Steroid drops suitable for ocular and aural use.
Fluorescein/amethocaine eye drops.
Decongestant/cold remedy.
Acyclovir cream.
Mouth ulcer treatment, e.g. Bonjela.

Topical

Flamazine or equivalent.
Hiridoid or equivalent.
Antiseptic, e.g. Savlon.
Sunscreen.
Topical steroids.

CNS

Migraine treatment.
Diazepam.
Sleeping tablet, e.g. zopiclone.

Obstetrics and gynaecology/contraception

Mefenamic acid.
Anti-fungal treatment.
Contraception.

You must be up-to-date with current doping regulations and which apply to the athletes under your care, e.g. in/out competition, IOC, WADA, International Federation. Some of the medications on this list require the completion of a TUE. Carry some blank forms.

Security and insurance issues

Increased security has restricted the ease with which a doctor can transport medical equipment and medication. I would encourage you to consider taking practical steps to preempt or avoid difficulty.

Itemize in full the contents of your medical bag.
Write to the Embassy of the country of destination detailing your travel arrangements and seek approval for the carriage of your medical equipment being sure to include your list.
Do not take strong opiate-based analgesia, e.g. morphine unless absolutely necessary, and then seek prior agreement. Many countries restrict even moderate or weak opiates not intended for personal medical use.
Where possible source medications in the country of destination, and certainly plan how you will replenish supplies locally.
Consider writing to the airline concerned detailing your medical luggage.
Carry a copy of your itemized medical bag and a letter confirming your medical role.
Ensure that any prohibited ‘dangerous’ (or potential prohibited) items are stored in the hold.
Do not take pressurized containers, e.g. oxygen, entanox.
Ensure that you have appropriate travel insurance.
Ensure that you have appropriate medical insurance and indemnity in order to practice in the country of destination.
Carry separately a photocopy/jpeg of your passport.

Team travel

Providing medical support to a traveling team presents the sports physician with additional challenges and adequate and timely preparation is essential. The following considerations should help you prepare for your team travel experience.

Selecting a medical team

You may be responsible for a team of medical officers. In these circumstances you should be involved in the appointment of your medical team and it is vitally important to get your team right from the start. This process should be just as any other professional appointment with a job description (including essential and desired criteria), application process with open job advert, short-listing and interview. Your interview panel should be multi-disciplinary and might include the team manager/head coach/chef de mission (or equivalent), chief physiotherapist, and a medical colleague (not involved with the sport or event in question). The appointments panel should meet prior to the interview to identify key questions that will allow the interviewee to demonstrate that they possess the necessary essential and desired qualities. In particular the ability to work effectively within a multidisciplinary team should be assessed.

It may be useful to have, within a team; doctors of differing sports medicine backgrounds, e.g. primary care, musculoskeletal, emergency care. In the future with specialty recognition and certified training programmes, doctors certifying in sports and exercise medicine (SEM) will have similar backgrounds and such distinctions may no longer hold true.

Medical preparation

Adequate preparation is essential whether you are the Chief Medical Officer to the Olympic team or the medical officer to an amateur team going on a club tour. The preparation will, of course, reflect the particular circumstances, but should follow good medical practice and applies irrespective of the stature of your athletes.

Team building

Get to know your team ahead of departure. In many circumstances you will already be part of a well-established team or squad. However, for major events, the headquarters staff may be from different backgrounds and you will almost certainly be working with a number of ‘strangers’. For this reason organizations arrange team building sessions, usually residential and often at weekends, which you should attend whether medical team leader or medical officer. They are invaluable opportunities to get to know other team members and facilitate preparation and planning. You should be prepared to advise your team on relevant medical issues including the ubiquitous ‘what if’ scenarios, e.g. what do we do if one of the team brings into camp a highly contagious form of viral gastro-enteritis?

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