ADAPTATIONS FOR THE ATHLETIC TRAINER: Responding to Emergencies in a COVID-19 World

Athletic trainers and team medical personnel face many challenges as they try to navigate COVID-19 protocols and keep athletes, and themselves, safe.  Some of these challenges have direct implications for emergency action planning and response, including personal protective equipment (PPE), new American Heart Association (AHA) changes to the BLS CPR algorithm, and acclimatization of deconditioned athletes.  In this issue of Sports Medicine Concepts’ Sports Emergency Care Digest we offer some suggestions based on intelligence we have gathered during simulation training that athletic trainers and team medical personnel may find useful.

Proper PPE:

The use of personal protective equipment has become the new norm within the general public. In athletics, the concern becomes who, what, when, and where proper PPE comes into play. Many questions still remain regarding the logistics on how to best protect yourself and others throughout the sports season.  An N95 respirator is designed to protect the wearer from inhaling airborne contaminants.  A surgical or cloth mask only provides barrier protection against large-particle droplets and does not effectively filter inhaled small particles, fumes, or vapors. Due to the high demand of N95 respirators, they have become very difficult to obtain. Without an N95 respirator, athletic trainers need to take extra precautions when within 6ft of another individual. This may require having disposable masks readily available for an injured athlete to don prior to evaluation. Gloves are another aspect of proper PPE that are now required when in contact with another individual regardless of the injury. During simulation training, the  SMC staff found that donning PPE on the way to the scene is more difficult than imagined. Gloves ripped or became stuck which inhibited response time.  We found that properly fitted gloves were key as well as having extras readily available. In some instances it was beneficial to be wearing at least one glove in preparation for an emergency.  We strongly encourage all athletic trainers and medical professionals to practice donning and doffing PPE to ensure that complications do not interfere with efficient care.

CPR Update:

The American Heart Association has updated the BLS Healthcare Provider Adult Cardiac Arrest Algorithm for Suspected or Confirmed COVID-19 Patients. Within the updated algorithm, there is an emphasis on the use of PPE prior to assessment as well as limiting personnel involved in the resuscitation.1 This sparks the question, what is the absolute minimum number of individuals needed to provide the best care for the patient in any given situation? The CDC also recommends minimizing exposure to  <15mins when in contact with a suspected or confirmed COVID-19 patient,2 which may require rotating individuals involved in a resuscitation.  During our simulation training, our staff found that the minimum personnel needed was 3 rescuers to maintain high quality CPR. This allowed one rescuer to step out between rounds of compressions to abide by the 6 foot social distancing recommendation. Consider practicing CPR with individuals who will be readily available to assist you on any given day, whether it be a practice or game-day situation.  The coaching staff can be of great assistance so no athletic trainer is ever alone.  The SMC program has long been a proponent of simulation and hands-on training as it provides the best opportunity for retention and limiting error when it matters most.  Consider recreating the CPR scene from our simulation video with your coaching staff.  A properly rehearsed CPR scenario can take as little as 10 mins of the coaches time and can drastically improve emergency response outcomes. 

The American Heart Association also clearly states in the updated algorithm that one must provide rescue breaths with a bag-mask device with filter and tight seal.1 In order to follow this requirement, athletic trainers should acquire both a bag-mask device along with a filter before the beginning of fall sports. One last change made to the algorithm is the option of a bag-mask device with filter OR continuous compressions with passive oxygenation using a face mask during CPR. The updated BLS algorithm provided by the American Heart Association is linked below for further review.

YouTube video timestamp for CPR 16:45

Acclimatization for the Deconditioned Athlete:

The bout of prolonged dormancy among athletes resulting from the current pandemic yields extra preparation for medical professionals. With a lack of activity and restrictions on access to fitness centers for an extended period of time, many athletes will return extremely deconditioned. Athletic seasons have also been rearranged in order to comply with specific regulations provided by each individual state. These changes increase risk of injury/illness in a multitude of ways. One area of specific concern is exercising outdoors in high/low temperatures with shortened acclimatization periods. Athletic trainers must be vigilant in the preparation and prevention of environmental injuries/illnesses. When activity takes place during high temperatures, proper hydration and a designated cooling zone are vital. This area should include a cold water immersion tub or supplies for the Tarp Assisted Cooling with Oscillation (TACO) method which are both affordable and effective ways to rapidly cool a heat stroke victim. 

Conversely, outdoor sports may stretch into the colder months in the fall and/or begin earlier in the spring. The combination of deconditioned athletes and cold weather conditions bring about a multitude of concerns ranging from muscle strains to hypothermia. With the change of seasons, cold related conditions may become more prevalent. Preparing a warm, dry, sheltered area with warming supplies can assist in treating these conditions. Athletic trainers can further decrease the risk of injury by encouraging coaches and their athletes to follow proper safe return to training guidelines. For more information on safely returning athletes to training, read the joint position paper published in the Strength and Conditioning Journal entitled: “CSCCa and NSCA Joint Consensus Guidelines for Transition Periods: Safe Return to Training Following Inactivity” linked below.

Korey Stringer Institute Return to Sports and Exercise During the COVID19 Pandemic: Guidance for High School and Collegiate Athletic Programs

https://journals.lww.com/nsca-scj/Fulltext/2019/06000/CSCCa_and_NSCA_Joint_Consensus_Guidelines_for.1.aspx

CSCCa and NSCA Joint Consensus Guidelines for Transition Periods: Safe Return to Training Following Inactivity

https://youtu.be/NxsVgddcE1E 

TACO Kit Supplies (email to purchase a TACO Kit from Sports Medicine Concepts)

YouTube TACO Method Simulation timestamp 42:27

YouTube Cold Illness Simulation 1:16:45

Secondary Risks Due to Climate:

Altered seasonal calendars will result in a greater number of athletes exercising under environmental factors that are known to predispose athletes to the onset of many conditions such as exercise induced asthma and anaphylaxis. With fall sports potentially extending into the colder months of winter and spring athletics beginning outdoor activities earlier in the season, athletic trainers must be prepared for the onset of these secondary conditions. Due to this increase in risk, it is vital to stay up-to-date on individual athletes with pre-existing conditions as well as maintaining a well established Emergency Action Plan (EAP).

Emergency Action Planning with Coaches and Athletes:

Practicing an emergency action plan prior to the start of every sport season has long been recommended to ensure the best possible outcome when an emergency situation arises.  Now, more than ever, it is imperative that athletic trainers review EAP’s and set aside time for implementation with coaches and staff. The AHA recommends using the least amount of personnel possible to perform high quality CPR. The CDC has stated that brief interactions are less likely to result in transmission and that 15 minutes of close exposure (within 6 feet) can be used as an operational definition of close contact.2 These recommendations may require an increased level of planning and rehearsal to keep the window of exposure time between individuals to a minimum.  Those individuals that are not directly involved in CPR or any injury assessment/treatment should stay at a distance of 6 feet to limit exposure.  Consideration to rotating roles throughout CPR or other close contact emergency responses should be taken so long as the quality of care is not diminished.  Coordination with proper PPE and an effort to limit time of exposure will require deliberate preparation.  Apart from the fact that having a rehearsed plan is crucial in providing the most favorable outcome for the injured individual, it is paramount in providing protection for the well-being of those providing care.

Interested in seeing all of the concerns addressed in the digest through simulated emergency response scenarios? Check out our recorded Athletic Training CE Event on YouTube https://youtu.be/eh-rkxuyY3Y

Resources:

AHA BLS Algorithm update

https://cpr.heart.org/-/media/cpr-files/resources/covid-19-resources-for-cpr-training/english/algorithmbls_adult_cacovid_200406.pdf?la=en

CDC 

https://www.cdc.gov/coronavirus/2019-ncov/php/public-health-recommendations.html

  1. BLS Healthcare Provider Adult Cardiac Arrest Algorithm for Suspected or Confirmed COVID-19 Patients.; 2020. https://cpr.heart.org/-/media/cpr-files/resources/covid-19-resources-for-cpr-training/english/algorithmbls_adult_cacovid_200406.pdf?la=en. Accessed September 9, 2020.
  1. Public Health Guidance for Community-Related Exposure. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/php/public-health-recommendations.html. Published July 31, 2020. Accessed September 9, 2020.

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