Development and Implementation of an Emergency Action Plan in Football

Abstract

Although uncommon, life-threatening injuries and illnesses do occur in American football, and the emergency response team must be ready to act when an emergency arises during training, practice, or competition. An emergency action plan (EAP) is central to the care of an athlete with a suspected life-threatening injury or illness. This set of step-by-step instructions on how the emergency response team will act during an emergency details the members of the team and their roles, plus information on emergency equipment, procedures at each venue, and the transportation of a player to the hospital. The emergency response team should keep the EAP up-to-date and rehearse annually.

Introduction

American football remains a popular sport, with over 4 million athletes participating across levels of competition [7]. As with any sport, football poses a risk of injury or illness to players. Although most injuries in football are of low severity and allow players to return after a period of rest or rehabilitation, catastrophic or life-threatening injuries or illnesses do arise, often unpredictably and without warning [1]. The most common catastrophic injuries or illnesses reported in football players are sudden cardiac events, sickle cell crisis, exertional heat illness, head trauma, and cervical spine injury [1,2]

The Annual Survey of Football Injury, conducted by the National Center for Catastrophic Sport Injury Research, reported 20 deaths in football players in 2021, resulting from traumatic brain injury, sudden cardiac arrest, and exertional heat stroke [7]. Furthermore, over the course of a 6-year period from 2015 to 2020, there were a total of 164 nonfatal catastrophic injuries or illnesses among football players, averaging 27 per year, including injuries to the cervical spine, brain, and internal organs [6].

Immediate care by trained medical personnel of the athlete who is acutely injured or ill is critical for the player’s survival and the reduction of secondary sequalae. In 2002, the National Athletic Trainers Association (NATA) recommended that each organization or institution that sponsors athletic events develop and implement a written emergency plan [1]. The emergency action plan (EAP) is a documented set of step-by-step procedures that outlines the care of critically ill or catastrophically injured athletes [1,8]. The EAP addresses a variety of scenarios the medical response team may have to respond to during a football practice, training session, or competition (Table 1). It includes the personnel involved and their roles in the response, emergency equipment, and venue-specific information. In addition, athlete transport procedures from the facility or field to the hospital are outlined. Despite published best practices related to EAPs, previous research has demonstrated that the adoption of these practices by institutions is still lacking [12].

Table 1.

Scenarios that should be addressed in the emergency action plan.

Emergency Scenarios
• sudden cardiac arrest • exertional heat illness/heat stroke • sickle cell crisis • head trauma • environmental considerations (lightning) • spine injuries • respiratory distress (asthma, pneumothorax, etc.) • anaphylaxis • abdominal/organ trauma • fracture • mass casualty/act of terrorism

The purpose of this review article is to highlight the importance of preparing and implementing an EAP as it relates to the management of serious illness or injury in football. Furthermore, this review will discuss the necessary components of the EAP, including personnel, emergency equipment, transport of the injured athlete, rehearsal, and documentation. Although the goal of this article is to provide a high-level review of emergency action planning in football, it is important to underscore that an EAP must be specific to each setting and resources available.

Emergency Response Team

An emergency response team (ERT) should consist of trained medical and allied health personnel, including at least the team’s certified athletic trainer and local emergency medical services (EMS). Depending on the level of competition and resources available, the ERT may include physicians, specialists in neurotrauma and airway management, paramedics, nurses, coaches, and law enforcement/security personnel. At minimum, members should be trained in the use of an automated external defibrillator (AED), cardiopulmonary resuscitation, first aid, and the prevention of disease transmission [1,3–5].

The ERT is responsible for identifying an emergency, quickly yet thoroughly assessing the athlete, and determining the type of response needed. Usually, the athletic trainer is the first on the scene and must assess the player and activate the EAP. The team’s training prepares them to respond to a range of catastrophic illnesses or injuries, including cardiac and respiratory events, exertional heat illness, traumatic brain injury, and cervical spine injury. The ability of the ERT to work efficiently as one unit is essential to delivering optimal care.

The EAP should identify the roles of ERT members during an incident—for example, who is designated to retrieve the emergency equipment and AED, activate EMS, and meet the ambulance at the designated location (Fig. 1). In addition, if personnel allow, one member should be designated to run the protocol. Managing the scene is a critical component of an emergency response, and it may be necessary to designate a team member who will clear the area around the downed athlete of other players, coaches, and personnel not involved in caring for the player.

Fig. 1.

The Emergency triangle consists of first responders arriving on the scene who will be involved in the initial evaluation of the injured athlete. Each position has a clearly defined role, ranging from assessment of the downed athlete to stabilization of the cervical spine, and, if warranted, equipment removal.

Photo courtesy Sports Medicine Concepts, Inc.

Communication on the ERT is essential to the execution of the EAP and ultimately the care of the athlete. Both verbal and nonverbal communication can be used. Hand signals can be used to communicate with the ERT to activate the EAP (ie, the “all come” signal) or call for a cart or for equipment needed for the response. More recently, the use of 2-way radios on the field has streamlined communication across multiple members of the ERT. Cell phones can be used to call EMS, the receiving hospital, or ERT members.

Emergency Equipment

Emergency equipment should be in a centrally located position where it can be retrieved easily by ERT members when needed. The type of equipment needed will depend on the type of emergency and is specific to the individual EAP (Table 2). In addition, it is important for team members to be familiar with the equipment carried by the local paramedics (onsite or responding to an emergency), such as emergency medications, intravenous supplies, endotracheal intubation equipment, and cardiac or other monitoring systems.

Table 2.

Listing of emergency equipment^*.

Emergency Equipment

• Automated external defibrillator with electrodes • AED prep kit (razor, gloves, scissors, CPR mask) • Pocket mask for CPR • Bag valve mask • Spine board with straps, blocks • Cervical collars • Rectal thermometer • People mover • Towels used for pack and fill • Vacuum Splits and pump • Facemask removal equipment (quick-release, quarter turn, extractors) • Cordless drill or screwdriver • Personal protective equipment • Oropharyngeal and nasopharyngeal airways • Stethoscope and sphygmomanometer • Manual suction device • Cold Water immersion tub • Epi Pen

^*Not an all-inclusive list, will vary based on individual EAP.

Emergencies involving football players may require the ERT to remove football equipment to access the airway and chest for ventilation or apply AED pads or chest compressions. The ERT should consider sudden cardiac arrest in a collapsed and unresponsive athlete. Immediate access to an AED and early defibrillation in individuals with sudden cardiac arrest has been shown to improve survival [3,5,10].

For a player with suspected cervical spine injury, equipment should be removed by personnel trained to do so to minimize cervical spine movement (Fig. 2) [9]. With advances in helmet, facemask, chin strap fasteners, and shoulder pad materials, it is imperative that the team medical staff and ERT stay current on available equipment removal tools and techniques. Many such tools exist and are specific to the type of fastener securing the facemask to the helmet (ie, quick-release, quarter-turn screw, traditional screw) and the connector at the breast plate of the shoulder pads (Figs. 3–6). Often, a combination of tools may be required to remove the equipment safely, if warranted. The team medical personnel should ensure that this equipment is in good working condition and that the use of this equipment is rehearsed annually.

Fig. 2.

(a, b) Hand position to maintain a neutral cervical spine when rolling player from prone to supine.

Photo courtesy Sports Medicine Concepts, Inc.

Fig. 3.

Traditional clip and screw.

Photo courtesy Sports Medicine Concepts, Inc.

Fig. 4.

Riddell quick release.

Photo courtesy Sports Medicine Concepts, Inc.

Fig. 5.

Schutt quarter turn.

Photo courtesy Sports Medicine Concepts, Inc.

Fig. 6.

Standard snap chin strap.

Photo courtesy Sports Medicine Concepts, Inc.

The different players on a team will be wearing a variety of helmet and shoulder pad models, and so medical staff must familiarize themselves with the models worn by each player. Communication with the equipment staff or coaches to discuss what is commonly worn by players and how often the hardware on the helmet is changed may also be advantageous. The variations in equipment and removal procedures should be reviewed annually so that an emergency is not the ERT’s initial exposure to these variables.

Emergency equipment should be checked frequently to make sure it is functioning appropriately. This may include, for example, recharging batteries in a cordless drill or screwdriver and replacing expired defibrillator pads. The location of the emergency equipment during activities should be included in the EAP. It is good practice to confirm the location of equipment prior to the start of each practice or competition.

Transportation

When discussing transportation of an injured or ill player, the ERT must consider ambulance arrival time once dispatched and transport time to the receiving hospital, as well as the time it takes to transfer the injured player from the field to the ambulance or stretcher. For a suspected spine injury or fracture, the goal during transfer is to minimize movement. Previous research has examined the use of several transfer procedures on cervical spine motion, including the 6-to-8-person lift or log-roll technique (Fig. 7) [9]. For exertional heat stroke (rectal temperature above 104° and symptoms of central nervous system dysfunction), the ERT must be prepared to quickly transfer an athlete from the field to an area for cold water immersion, as rapid whole-body cooling is essential for survival. Rectal temperature assessment is required for suspected heat stroke as the only reliable method of body core temperature assessment. The athlete must be cooled to a core body temperature of less than 102°F (38.9° C) prior to transport [3,11].

Fig. 7.

(a) 8-person lift. (b) 8-person lift with spine board placement.

Photo courtesy Sports Medicine Concepts, Inc.

The medical team should be trained in multiple transfer techniques and apply their best judgment as to which technique to use during an emergency [1]. This depends on the type of emergency, the position of injured athlete (supine or prone), and the number of people available to assist. Regardless, a rehearsal of each technique should be part of annual EAP training [1].

Onsite presence of an ambulance for football games and practices has become widespread. The response time to emergency events should be carefully considered when deciding if onsite coverage is necessary. Whether onsite or dispatched, the ambulance should have clear entry and exit to access an injured player. Communication with local EMS teams will determine how they will respond if an additional ambulance is needed and the estimated response time.

Identifying the receiving hospital for injured players should be discussed when the EAP is developed and annually during rehearsals. The type of emergency may dictate which hospital is appropriate, as different facilities are better equipped to handle certain emergencies. In addition, stability of the injured athlete at the time of transport and travel time to the facility should also be considered when determining a receiving hospital. It is incumbent on the ERT to understand where the patient needs to be transported to and who will be receiving them upon their arrival. Identifying contacts for each medical facility when developing an EAP will provide the ERT a point person in the event of an emergency. It is good practice to contact the receiving hospital in advance of the athlete’s arrival.

If an injured player is transported with helmet and shoulder pads in place, a person trained in the removal of equipment should accompany the athlete to the emergency department (ED). Smaller medical teams should provide periodic in-services to a hospital ED that is likely to receive injured athletes. Football equipment removal is not routine practice for ED personnel, for whom training would be necessary if an equipment-laden athlete were to present to their facility.

Venue Considerations

Each venue may present its own challenges in the management of a critically injured player. For that reason, an EAP should be prepared and maintained for each venue where practice and competition occur, including accurate address for each venue, with maps, pictures, and other landmarks that might assist with quick response. It is important to identify ambulance ingress and egress points and barriers that might prohibit quick access to an injured athlete, such as identifying locked gates for field access and obtaining a key.

It is good practice to meet with the local paramedics or emergency medical technicians yearly to walk through athletic facilities so that they become familiar with the building, entrances, exits, and traffic patterns should an athlete need to be treated and prepared for transport. The best access to the field, facility, or athletic training room or staging area for the ambulance during an event can be discussed at that time.

A visiting team’s arrival at an unfamiliar field or stadium can present new challenges for the ERT. The visiting medical staff should familiarize themselves with the EAP of the venue in advance, including activating EAP, locating EMS or paramedics, where the ambulance is located, what equipment is available, and preferred receiving hospital.

A pre-event medical meeting, or medical “time-out,” has gained popularity in sports medicine and is recommended [1,4]. This meeting, held prior to the start of the competition, familiarizes the visiting team’s medical staff with the local emergency response team, everyone’s role in an emergency response, the available equipment, the location of the ambulance and EMS, and venue-specific EAP and transportation procedures. The National Football League (NFL) implemented this “60-minute medical meeting” in 2017, in which team medical staffs convene with game officials, athletic trainer spotters, unaffiliated neurotrauma consultants (UNCs), and visiting team medical liaisons (VTMLs) at a centralized location an hour before the game.

The home team medical staff can provide visiting team medical staff with pocket-size reference guides that include phone numbers and locations of EMS, ambulance, and the local emergency equipment. A list should be maintained of player emergency contacts and pertinent information such as allergies, current medications, and medical conditions. The practice of both the 60-min medical meeting and the reference guide can be adapted to all levels of competition.

Rehearsal and Documentation

The EAP should be reviewed and rehearsed by all personnel at each venue annually, although more frequent rehearsals may be necessary [1,3–5,8]. This rehearsal should include team medical staff, such as athletic trainers, team physicians, local emergency medical personnel, and paramedics. Depending on the setting and level of competition, others may include physicians specializing in airway management/intubation, neurologic injury, and spinal injury.

Rehearsals may involve emergency scenarios such as the collapsed athlete, potential head/neck trauma, and heat illness, among others. Equipment removal, athlete transfers such as the log-roll or 6 to 8 person lift technique, or athlete transfer from the field to a cold tub may also be rehearsed. The objective is to challenge the ERT and identify potential gaps in the EAP —for example, a scenario with 2 concomitant emergencies that require competing resources. It should also be used to build consensus across the ERT, especially in areas when ERT procedures and EMS protocols may differ (such as cool first, transport second in cases of exertional heat illness). Given that football is an equipment-laden sport, it may be necessary to work with the local hospital’s emergency department to train personnel on proper equipment removal if an athlete is transferred with equipment in place.

Documentation on the rehearsal should include the date of completion and a list of those in attendance, which can be stored for retrieval at a later date if necessary. The EAP should be updated to reflect changes that were discussed and implemented in rehearsal. The EAP should be provided to all members of the ERT annually.

Documentation of the emergency event should also be completed whenever the EAP is activated in the care of an athlete. This information is critical information not only for the individual athlete’s care but also be for a retrospective review of the ERT’s response. An after-action review with the ERT can be a valuable tool in quality improvement and ongoing preparedness for future emergencies.

Medicolegal Considerations

Clinicians have legal and professional responsibilities to ensure high-quality care is provided to their patients [1]. An EAP can define the standard of care for clinicians responding to an emergency [4]. Failure to develop or implement an EAP has been the basis of lawsuits claiming negligence on the part of practitioners failing to provide the appropriate standards of care to patients [1]. It is paramount that the ERT maintain current and regularly rehearsed EAPs for all training, practice, or competition venues.

Conclusion

The evolution of protective equipment, rule changes, advances in medical care, and improvements in coaching and training and conditioning techniques all aim to make American football safer for participants across all levels of competition. Although uncommon, catastrophic injuries can occur in football. An EAP should be maintained at any venue where practice, training, or competition occurs. It should be designed identify members of the ERT, address potential scenarios, establish the available emergency equipment, address venue-specific considerations and athlete transportation to advanced care. The EAP must be comprehensive yet have the flexibility to adapt to multiple situations across a spectrum of potential emergency and catastrophic injury situations. A well-rehearsed and well-executed EAP should be considered the first line of defense against catastrophic injury in football and remains central to the care of injured athlete and ultimately the ability to deliver a successful outcome.