1. On-Field Emergency Management Equipment Removal And Spine Boarding

2. Mountain Brook, AL Fire Department ◦ Chief Chris J. Mullins – MSEM, Paramedic ◦ Jody Box – BS, PSHA, Paramedic, Firefighter ◦ Lee Rhudy – Paramedic, Firefighter ◦ Nathan Rhudy – Student ◦ Noah Johnson – Paramedic, Firefighter ◦ Jon Head – Paramedic, Firefighter Hoover, AL Fire Department ◦ Chief Frank Brocato Marybeth Horodyski, EdD, ATC, LAT, FNATA Professor and Director of Research Department of Orthopaedics and Rehabilitation

3.  Recommendations based on current research.  If research was not available, recommendations were based on the consensus and expertise of Emergency Responders and Athletic Trainers.

4. Near Perfect Situations  No extrication from crash  Flat surface  Crowd control and extra hands from coaches  Knowledge of history and medical conditions  Most injuries are orthopaedic  Mechanism of injury is usually witnessed and injury is known Non Perfect Situations  Unconscious athletes stuck together by facemasks  More than 1 major injury at a time

5.  Take a proactive approach o Exchange ideas among professionals (How can jobs be made easier and more efficient?). o Encourage schools to require an ‘Athlete Emergency List’ and completed ‘Permission to Treat’ forms on the sideline. Many schools will not have these on the field.

7.  AT signal for Dr. and/or EMS o Head, Neck, Spine Injury o Athlete is unconscious o Athlete is not breathing o Other significant injury (certain fractures and/or dislocations)  AT remove facemask only after manual stabilization. o Trap Squeeze causes less movement and more control than other methods o Face mask should be removed at the earliest opportunity, before transportation and regardless of current respiratory status

8.  Cervical Collar – Causes too much movement to try to apply unless helmet and shoulder pads are removed. Do not force it. Cervical collars sometimes do more harm than good.

9.  Properly fitted football helmet and shoulder pads will hold head and spine in neutral position.  The front of the shoulder pads can be opened to allow the rescuer access to the athlete’s chest for: o Evaluation o Listening to breath and cardiac sounds o CPR chest compressions o Defibrillation

10.  Will you remove helmet and shoulder pads on the field only if it is determined to be medically necessary?  Will you remove helmet and shoulder pads on the field as standard protocol for transport?

11.  EMS takes the lead in stabilization and packaging  Athletic Trainer takes the lead in equipment removal  Call for extra help if another set of hands is needed  Parent/AT/Coach/School Official supply information for history. (Athlete Emergency List, Medical release)

12.  EMS/AT Post Season Review. o What problems occurred? o What works and what doesn’t? o Where can improvements be made? o How can we work together better?

13. Injured Athlete On Field Care and Equipment Removal

14.  Demonstrate, teach and practice proper football equipment removal  Practice challenging situations in spine boarding

15.  Circulation Airway, Breathing  Level of Consciousness  If conscious, what is initial complaint (What is wrong? What hurts? What did you feel? Etc)  Neurological Status (Cranial Nerve Assessment, What moves?, What doesn’t move?)

16. Questions After Initial Assessment  Hold C-Spine / Don’t Hold C-Spine  Transport / Don’t Transport  Remove Equipment / Don’t Remove Equipment  AT should communicate a brief assessment to EMS so that everyone is on the same page.

17. Reasons to Remove Equipment  Helmet is off  Helmet is twisted so that airway is not accessible  Helmet is loose and does not secure the head  The facemask cannot be removed

18. IF EQUIPMENT REMOVAL IS DECIDED UPON, THEN.......

19.  This is the wrong time to fight over ‘control’.  The word ‘Control’ is seriously misused.  Person at head usually has ultimate control o Acknowledge comments from other professionals o Transfer of C-Spine/control is sometimes necessary. Exception to C-spine control: If a lay person has been recruited to hold C-spine, then the medical professional with the most experience will retain control.

20.  Call EMS  Determines equipment removal  Remove facemask when C-Spine is secure regardless of current respiratory status  Remove mouthpiece if necessary/Find mouthpiece  Be prepared to communicate quickly: o Mechanism of injury o Chief complaint if athlete is conscious o Signs and symptoms o Medical history: Allergies, medical conditions *Communication is key!

21.  Hold C-Spine – Trap Squeeze causes the least amount of movement  Take instructions from AT who is removing equipment  Determine boarding technique with AT ( Recent research shows that lift and slide causes the least amount of neck and spine movement unless unusual circumstances prevent this technique) *Protocol for checking vitals is every 5 minutes.

22. Prepare the Equipment

23. HELMET  Cordless screwdriver  Screwdriver  Trainer’s Angel, FM Extractor, Anvil Pruner  Ball Needle for Quick Clips  Blocks (rolled towel) to stabilize helmet or head  Small flashlight SHOULDER PADS  Heavy Sharp Shears

24.  Cordless screwdriver – People forget to recharge battery; causes little head motion  Screwdriver – Causes more head motion than cordless screwdriver  Box Cutter/Knife – Causes extreme head motion and possible injury to rescuer  Anvil Pruner – Efficient when sharp  Trainer’s Angel – Causes movement; hard to use  FM Extractor (Revolution)- Expensive; hard to use without practice

25.  Remove helmet first and shoulder pads second. Never remove one without the other.  Spine board should be in position  AT will prepare helmet and shoulder pads while EMS holds C-Spine

26. Common Helmets: Revolution Speed Schutt Xenith

27.  Plastic clips attach face mask to the helmet o Remove all 4 clips. DO NOT remove side clips and flip facemask up. o If 1 clip cannot be removed, continue to next clip. o If possible, place pressure on the underside of the clip while unscrewing. o Place hand between removal tool and athlete’s face o Quick release clips can be tricky

28. This type of clip can be found on the Riddell Revolution Speed helmet. Quick release clips can be tricky. This clip is removed by inserting a ball needle into the metal center. Once clip is released, lift from both sides at the same time to remove.

29.  Chin Strap o Cut bottom straps on both sides first to prevent helmet from rotating onto athlete’s face o Cut top straps on both sides second o Never try to unsnap * Chin straps should not be cut unless CPR needs to be administered or the helmet needs to be removed.

30.  Air Bladder – Do Not Worry with Bladder o Holes to deflate are located on the top, back and at the jaw of the helmet. o Many times they are not aligned and do not work properly anyway

31.  Helmet can be removed with cheek pads intact.  Some pads are secured with Velcro only o Some pads are secured with plastic in addition to Velcro. Helmet Removal

32. Prepare shoulder pads for removal before continuing.

33.  Remove uniform top or jersey. Cut top to bottom (neck to hem) and out through each sleeve (neck to wrist).  When shoulder pads are exposed, cut through strings and straps.

34.  Be aware that other equipment may be attached to or under shoulder pads. o Rib protector o Cowboy collars/ neck rolls o Shoulder shockers/ spider pads o Kidney protector/ back flap o Shoulder stabilizer/ Shoulder Braces

35.  Rescuer #1 continues to hold c-spine with trap squeeze technique while equipment is being prepared  Rescuer #1 transfer C-Spine stabilization to rescuer #2 who assumes control from the front while straddling the athlete

36.  Rescuer #1 (at the head) grasps the helmet at the ear holes and gently removes it from the athlete o Pull straight off.

37.  Rescuer #2 (holding head from front) will have to hold head slightly elevated to keep in line until shoulder pads are removed  Additional rescuers may be needed to assist with shoulder pad removal. o Determine if only shoulders or entire upper body needs to be lifted Helmet/Shoulder Pad Removal

38.  Rescuers #3/4 place hands inside shoulder pads on athlete’s scapula and prepare to lift athlete on rescuer #2’s count.

39.  Rescuer #1 will remove shoulder pads  As with helmet, shoulder pads are pulled straight out while being removed.

40.  Once shoulder pads are removed, on #2’s count, lower athlete to the ground  Rescuer #2 (holding head) returns C-Spine to rescuer #1.

41.  Apply cervical collar  Continue spine board procedures

42.  Chin Straps – Some will need to be removed in order to remove facemask. (ex. If chin strap is attached incorrectly)  Remove mouth piece if necessary. Some may be cut down to fit in mouth but not attached to helmet.

43.  Unrolled tape under the spine board may be used in stabilization of helmet.  If equipment is left on, a rolled towel may be used for neck stabilization.  During pre-season assemble an emergency equipment removal kit.

44. HELMET #1 Manually stabilize C-Spine Facemask – Mouth piece Bottom Chin Strap Both Sides Top Chin Strap Both Sides SHOULDER PADS Remove Shirt Cut Strings & Straps Look For Attached Equipment

45. REMOVAL *At least 4 people needed for removal #1 Transfer C-Spine to #2 #1 Slide Helmet Off #2 Initiate Lifting Athlete With #3 and #4 If Necessary #1 Slide Pads Off With Help From #2, #3 and #4 #2 Initiate Lowering Athlete #2 Transfer C-Spine To #1 #2 Apply C-Collar

46. PRACTICE !

47.  Standard Spine board  Scoop Stretcher ◦ Must consider height and weight ◦ Check latches at top and bottom  Vacuum Mattress ◦ Can use lift and slide or log roll ◦ Standard in some other countries is Scoop to Vacuum Mattress

48.  Lift and Slide ◦ Marybeth Horodyski’s research shows LS to cause the least spine movement ◦ Ideal to have 3 people on each side ◦ 4 people on each side for larger athletes ◦ Lift again to center on board ◦ EMS has been using LS for quite some time

49.  Log Roll ◦ Must be used if athlete is prone ◦ Ready spine board and roll athlete onto board ◦ When LR, push onto board don’t pull ◦ LS to center

50. QUESTIONS?

51. LET’S PRACTICE