Medical Time-Out Helps to be Aware, Prepared and Educated

Minimizing risk of injury in high school sports has always been a priority for the NFHS. With rules changes, equipment improvement, concussion protocols, sideline AEDs and, most recently, infection-control measures during the COVID-19 pandemic, this has become a very important topic.

During the past few months, several articles in High School Today have highlighted these priorities. In particular, an article about the Medical Time-Out puts the planning of the Emergency Action Plan as written by Dr. Weenig in last month’s HST into the hands of those actually onsite and potentially implementing the EAP at the sports event.

With the uniqueness of high school sporting contests, school administrators and medical personnel recognize that these are high-profile community events with inherent athlete and spectator injury and illness risk.

The intent and purpose of focusing on the Medical Time-Out is to prepare school administrators, athletic trainers, coaches, EMS providers, team physicians, game officials and anyone else designated as responsible for the well-being of students or spectators to simply be aware, prepared and educated.

Communication among these individuals can make the difference between a positive outcome and a negative experience if and when an injury or incident occurs.

Overview
The Medical Time-Out should ideally be initiated 15-30 minutes prior to the event and document the names and cell phone contacts for all individuals who participated in it. Event sideline and press box radio communication is recommended but optional.

AED locations in the venue should be recorded. Sentinel seizure awareness by all team members for on-field, in-play athlete collapse from sudden cardiac arrest (SCA) should also be confirmed.

Hand signals for EMS response to the field of play with the need for backboard, ACLS support and suspected extremity fracture need agreement and rehearsal. Procedures for head and neck injury should be reviewed with a captain assigned for c-spine control, face mask, equipment removal tools and agreed technique for boarding (multi-person lift or log roll).

Any spirit team member such as cheerleaders or flag runners and band member injury designated responders as well as spectator illness assignments should be addressed and recorded during the Medical Time-Out. Crowd control and incident designee staff assignments are also important.

In geographically isolated locations there should be a designated Aero-medical landing zone with coordinates and also a back-up EMS assignment when coverage is limited to a single rescue unit. (Appendix 1, The Friday Night Medical Time-Out checklist)

Emergency Action Plans
The sheer number of high school students participating in sports across a vast differing set of locales and venues leads to a very heterogeneous mix of resources to provide prompt emergency care for scholastic athletes. In addition, recent studies show 66 percent of high schools have access to certified athletic trainers and they are not at every practice or event. Most high school athletic directors report having a published Emergency Action Plan (EAP) and coaches certified in CPR/AED.

Without exception, the EMS squads with responsibility for high-profile community sporting events need to be “out of the parking lot” with strategic venue positioning to promote precision of response. This is especially important in more remote locations with limited resources. Because of work shortages in EMS personnel, very frequently on-site ambulance coverage is uncertain up until gametime. In addition, personnel are often called away from sports events due to other situations such as motor vehicle accidents or even medical events like chest pain. Contingencies for how things will work if the resources change must be considered and discussed in addition to the “normal” Medical Time-Out topics.

Worse Case Scenario Preparation
The secondary school Medical Time-Out design needs to provide guidance for the rapid recognition and initial management of potential catastrophic athlete injury. Emerging trends in sports trauma should be addressed. Athlete sudden cardiac arrest (SCA) with sentinel seizure, eyes open and agonal respiration awareness and blunt chest trauma cardiac arrest (Commotio Cordis) both require prompt response.

In addition, delayed cardiac arrest associated with sickle cell trait collapse and core temperature measurement and rapid cooling prior to transport in exertional heat stroke are unique to athletic venues. Penetrating trauma hemorrhage control (stop the bleed) and spinal immobilization equipment preference and technique need to be addressed during the Medical Time-Out.

Head, Heart and Heat Trauma
Sports concussion management should be discussed during the Medical Time-Out. Athletes with a recent concussion history are of particular concern and are at risk for secondary injury. Preevent circle of roster number provides opportunity of “extra eyes” for early identification if a repeat injury occurs. This is consistent with NFL and NCAA football emphasis with assigned spotters for suspected head injury.

Intense exercise is a trigger for sudden cardiac arrest (SCA) in athletes with unrecognized congenital heart conditions. Sudden collapse during sports play should be considered cardiac in origin. The unresponsive athlete needs rapid chest exposure for AED placement with a high index of suspicion for a cardiac etiology.

Heat stress is common in high school sports participation. A core temperature should be obtained in cases of suspected heat trauma. If the rectal temperature is above 104 degrees (F) in an athlete with altered mental status, Exertional Heat Stroke (EHS) treatment with rapid on-site cooling with ice water immersion should occur prior to Emergency Department transport. (“Cool First-Transport Second”)

Athletes with known or suspected sickle cell trait (SCT) are at risk for heat stress. Sickle cell trait athletes with bilateral cramps, back pain and shortness of breath require a high index of suspicion for pending exercise-related collapse and consideration for early supplemental oxygen, cardiac monitoring and IV fluids.

High School MTO Extras
Adding a Universal ALL-CALL as “Arms Crossed Over Head” signal for serious athlete injury or illness with immediate venue Emergency Action Plan (EAP) activation provides rapid response for team physician and fully equipped EMS to the field of play. Crowd control is essential to maximize coordination of the rapid response team. Positioning teammates clear of the downed athlete and near the sideline with support from appointed “Incident Designee” for acute stress management and family outreach is optimal. The inclusion of mental health awareness to EAP development has been endorsed by the NFHS leadership.

In addition to the attending health care personnel, the participation of the head official during the pregame Medical Time-Out is optimal. The game-day referee has initiated the NFL “60-Minute Meeting” at a predetermined stadium location since 2017 season. Adding official involvement provides structure and timing for the Medical Time-Out and “extra eyes” for early injury recognition.

The Korey Stringer Medical Time-Out available on the KSI EAP website has provided a valuable resource the past five seasons for scholastic sports medicine staff in states prone to heat stress. This pre-game checklist provides a good option for implementation in high heat risk locations.

Note: Dr. Kyle and Dr. Elkins coordinate yearly checklist updates and offer training tutorials for staff education and Medical Time-Out implementation. The current 2023 MTO is available online with search of The Friday Night Medical Time Out. This update is designed to enhance MTO efficiency with a “Fillable PDF format” for pre-event entry of home team staff, phone contacts, designated cheerleader, band, spectator responders, and landing zone coordinates to share with visiting team and EMS during the checklist review.