Transcript

0:04

Hello, everyone. Ray Castle. Thank you again for signing in for session 2 today. Of the sport to merchant care symposium 1.0. Have a fantastic guest today with Edstrap.

0:16

We'll talk about airway management in the equipment laden athlete. This really this one session really goes in line with what are 2 of Doctor. Marybeth Hordiski and also Ron Courson provided on the other their presentations earlier in the week. And this is will be no exception. So a couple those of you who may be may have a couple of people that are first time few or seeing a session this week.

0:42

One is in the q and a, we have a button there. Make sure you Submit your questions whenever during the presentation with about 10 minutes left, give or take. We'll start we'll Edley Fishman's presentation, and we'll go right into a a q and a session. Also, just make sure if you'd like to ask a question person, just raise your hand. They'll button there.

1:09

And we will I will turn the audio on, and you get to have that conversation with Ed. Adds a lot to that as well. So along those lines. So, again, those in the chat area, let us know where you're from. Just helps in the context of where we're going through discussions and how we can how a note from Ed's perspective how to handle those those questions and more tailored to your setting.

1:33

Hey. Good morning or after I'm sure the afternoon, I should say. So how are you doing today?

1:43

I am good. Hello, everyone.

1:45

Right. It is a it is a pleasure to have you know, Ed Ed have you here today. I've seen you do you do some great work. Just kind of give a overview of what for those of you don't know who Ed is in addition to does like good barbecue, I believe. Is that right?

2:03

I think that's one of them.

2:04

I try. Some people seem to like it.

2:06

Yep. And Baker works on a good conversation beforehand, but Most importantly, for this presentation, so Ed has a wealth of experience in emergency medicine. You ever get a chance to hear him and they and what they're doing with sports medicine and merchant management, they do some really great work. And I'm just excited to have you on the on the presenting today. So, Ed is he's currently a a trooper and fight paramedic with the Maryland state police.

2:33

He's also active with US ski and snowboard teams. So you were over, I think, in Europe about a month or so. I've got you for about a month. Is that right? You were traveling over there recently with the US key teams.

2:46

He's been certified for over 20 years. Worked in EMS for last since 2010, and just in addition is also co owner for Sports Medicine Emergency Management. So I'm gonna turn it over to you, Ed. We've got about, you know, less a little less than an hour left. So I know you're gonna rock it.

3:05

So It's all yours.

3:07

We'll we'll try to make it we'll try to make it happen and stay on schedule. So I I can't think enough you know, on behalf of Sports Medicine Emergency Management myself. It's it's great to be involved in part of part of this program. As as you said, we're kind of talking about airway management, particularly airway management for the equipment laid in athlete. And that's a challenge.

3:30

Because us we in athletic training don't do this very often. But when we do, it will be it could be a a real game changer. So you know, it's great to be a part of this, sorta, you know, roll in on the end and and be able to change some thinking and have some fun and and just to be in the same realm with everybody that's been presenting this week has been phenomenal. As Ray said, I'm a trooper flight paramedic with the Maryland state police. We run all the service in the state.

3:59

Been certified for quite a long time now. US ski and snowboard team. And an exciting little piece that I haven't told many people is I'm headed to 2 Olympics next year. So I'll be headed to the youth Olympic Games in January, and I'll be headed to the the full Olympic summer games in Paris next year. So, you know, it's really exciting to be able to take all of this and, you know, put it all together.

4:21

So just a few things that I do and and get to play with. No no disclosures except that I am co principal with Schwartz Medicine Emergency Management that really we with Daryl Conway, we've tried to elevate the emergency care of athletic trainers and other sports medicine providers on the sideline and what we can do. Anytime we talk about medicine and and medical interventions, always make sure you check your practice act, your local protocols. Check with your team physicians, your medical directors, and your employer, and make sure that they're on board with all of these interventions. While these are all part of our practice act, our KD standards and other pieces, it's really important that, you know, you're you're following the guidelines that you have.

5:08

It is always better to be prepared and not have the opportunity to do something than get into that moment where you have that up opportunity and you're not prepared. So even though you've been in your career, maybe a couple of days, maybe a couple of years, maybe 20 years, and you said I've never done this, it doesn't mean that you won't. And that's what we really have to think about as being prepared for that catastrophic event that we may be you know, a game changing intervention. So we'll look at at the various aspects of the NATAs Spine Injury And Sport Group, Emergency Medicine Recommendations. We'll discuss what our role is in the healthcare team.

5:46

And how we can all play together, and then talk about how we can implement these interventions. You know? Because this is this is really why we're here. This is that moment that, you know, we're we're thinking about. There's your athlete laying on the field Obviously, something is not right.

6:07

He's in that fencing postures. He's in that position. This was last year. This was actually the first I say, on field, but, you know, in in the facility, advanced airway procedure in the NFL where they did RSI him. To stabilize him and secure his airway.

6:26

You know? So this is these are the these moments. They they hit. They're they're fast. They're hard, and we know something's not right.

6:33

So maybe an athlete takes a puck off the face. He actually died ultimately of these injuries coming from you know, that that trauma to the face. And and that's what we have to be ready for, but it's at all levels. It's not just at the college level or the professional level that, you know, we have size mismatches, we have inner we have have athlete conditions and positions. So are you ready?

7:01

That's the question, and that's the question for today. And hopefully, you know, when we start here, You may be on the fence by the time we get done today. You know that where you need to go to get the training and the skills to be prepared, you know, for this. Because is this the day? Is this when we need to be ready?

7:22

You know, this this sign was posted around a number of bases forward basis during the Afghan and Iraqi wars, and it was really talking about are you ready? So they were kinda looking at, are you ready to die, are you ready to get wounded, or are you ready to perform that heroic act that may save others. And that's what we have to be ready for. We have to be prepared for this. So we know that no matter how long you've been in the game, at some point, you'll have this in your career.

7:56

Our life can can change very quickly. Going from sitting on the sidelines, feet up in our gator, eating our our dinner because it's the last game of the night, and it's, you know, the 8th inning in baseball, and we get complacent, we get comfortable, and we're not necessarily ready. How you prepare is really going to help you and how you manage and how you recover after an event like this. Just had a phenomenal talk about mental health with our athletes. But we also have to think about ourselves, and we have to be ready.

8:27

So when you prepare and you are ready, you have that mental preparation for this event, it's gonna allow you to have a better mental fitness after the event. So it's really important as we go home and go back to our lives, We may have an athlete that's critically injured, and we may be one of the few people that are going back to work. We have to shake that off and get back in the game Go to cover another game, stay later that night, whatever the case may be. We can't always just cancel the game, end the day, and go take care of that one athlete. We've passed them off.

9:01

So as you prepare for an event like this, you have to remember that column is contagious, but so it's panicked. So Be be comfortable with yourself, your skills, your management so that you're ready to provide these skills. Part of that comes with training, and I'll talk a lot about training because this is a skill we don't do a lot. We need to train with a sense of urgency. This doesn't mean just set the mannequin up on a table.

9:28

Walk in whenever we're ready. Excuse me. Walk in whenever we're ready and just provide a little bit care, create realistic scenarios, and realistic training that is going to help you develop. Because right now, we all sit in the comfort zone. We all sit in a safe, comfortable environment.

9:44

Hey, this never happened. I've never needed this. We don't really wanna challenge ourselves to get new skills like this. Because, well, we don't have the confidence. We don't wanna look foolish.

9:55

We're gonna find you know, we're too busy, things like that. Find a way to get through that theirs zone into the learning zone. So now we can face our new challenges. Meet with your local EMS, train with them, bring them into you, Now you provide equipment management. They provide some airway.

10:12

You all work together, and now we start to get into that that learning zone and ultimately the growth zone. Which is gonna allow you to really realize that this could be the moment that we're saving our athlete from the grave. This could be that moment that we need to be ready, and we need to be prepared. So don't go into this thinking something can't or won't happen. Because that's just not being prepared.

10:36

Go into the this with the moment that if it is predictable, it is manageable. So before I get too far along. I really like this slide, so we start to think about how we package our equipment, how we prepare our equipment, what we do with our ourselves to be ready. All of us are sitting probably in this this resting heart rate, 60 to 80 beats per minute. We're really we're relaxed.

10:58

We're chill. Look at your watch, see what your watch tells you, your heart rate is, and we can do everything we want. We can pick up a pen. We can open up a lot. We can Grab our keys, unlock a lock, get through a door.

11:11

We can do all of those things. We can open up the package to the band aids. We can do all of those normal things. Things. As we start to increase our fine motor skills, and you see, Daryl has changed my yellow to maze.

11:27

Love him to death. As we get into this this maze side, our heart rate starts to increase. We lose fine motor skills. This is a time that you can open the package on your airway. You can't open the package on your tourniquet or your wound packing any of those devices because we've lost our fine motor skills.

11:45

As our heart rate increases, our complex motor skills decrease, now we really start to fail in more tasks. Some of our gross motors still work. We're bigger. We're faster. We're stronger.

11:56

We believe a little bit less, which is great. But if I can't do gross motor skills, and we we see incidences of this where somebody will go up to the panic bar on a door, miss the panic bar, and they can't figure out how to get out the door because They're just they're starting to get into that condition gray, but their gross motor skills are are are really started to go out the window. So as we start to prepare and train and be ready to provide a skill that we don't do very often, all of a sudden, we have to add this stress in that we're ready to do these skills in a very challenging environment. Our athlete, our coach, one of these individuals that we're responsible for, is now not able to breathe, and we have to intervene with that. And it's really gonna be critical for us.

12:44

As we get into condition gray, now we start to get that tunnel vision, the auditory exclusion, time dilation, all of this happen. So we're screaming that EMS isn't there yet, but it's only been a minute or 2. Maybe somebody is chattering beside you, trying to drive you to perform a skill, and you have just totally blocked them out because you're just so tunnel vision focused on this one thing. And it may be that you can't get the nasal fair and dual airway in or an oral fair and dual airway. You can't get a good mass deal because the helmets in the way but all you're doing is struggling to get the mask seal and not realizing, hey, maybe if we take the helmet off, if we do other things, maybe I can you know, improve this intervention.

13:24

And then our condition black is our heart rate increases. You know, we start to go into system overload. You know, we may freeze. We may have bowel bladder issues. Ideally, we're gonna stay out of that.

13:35

But I promise you, if I run out the center field, my heart rate's gonna be at about a 100 20 beats per minute. I'm not gonna be as fully functional yet until I can slow myself back down. So be ready for that. Think about Because in times of training, you will always in times of stress, you'll always follow the level of your training. So we do training.

13:54

We're like, ah, yeah. But if it was real life, I would have done this. I would have done that. It's really important to think about these things as we start to to develop. So Let's get into this.

14:05

How are we gonna manage the airway in our equipment laid in athletes? First of all, we have to think of the environment that we're in. Are we in practice or are we in games? How many athletic trainers do we have? What other resources do we have?

14:17

That is going to dramatically change how I manage my student athletes. So, you know, in the college setting, 91% of all injuries occur in practice and only about 10% of the injuries occur in games. So we we always think about and train with our team physician, with our Friday night lights, with all of those pieces. We go through our pre event medical time out, we're already when the cavalry is there. But what are we gonna do an hour before practice when we're in our athletic training room?

14:48

And something happens in the locker room or upstairs in a coach's office. How are we prepared to perform these skills equipment like an athlete or not, you know, to to go for it. So what we are happening now think about is all of this equipment that our athlete is wearing, whether it is in football or ice hockey, field hockey, whatever the case may be. All of these pieces of a safety equipment in some capacity have failed our athlete and our patient, and now they become a hindrance for our ability to provide this care. So we look at this, these pictures back there, and we think about all these different athletes and all these different types of equipment.

15:28

This is not just football. This may be our catcher. This may be motocross or BMX. This may be ice hockey. Maybe it's not equipment that they're wearing, but now they're in a foam pit.

15:41

They're in a skateboard. They're on the side of a hill. All of these pieces are going to have an impact in how we provide this this care. So we know that, you know, it is it it may be a critical sudden incident like that hockey player getting a a puck across the jaw. It may be something that is just progress sing slowly and may progress over time that we're missing it, we're not intervening appropriately early on.

16:11

So we have to practice these skills because they are mechanical skills that we are going to lose. So we can't just practice this, Once, twice, once a year, this has to be something that we practice on a regular basis. And how do we do that? Let's build a team. Alright?

16:30

A team of experts is not an expert team because even if we've got the best providers, if we're not working together, we're not going to be the most effective that we can. So you need to understand who you have available on your team. Is it coaches? Is it athletic training student aids? Is it physicians?

16:52

Is it EMS? Where are we? And how do we build this team that's together very strong because it comes from practice. So those are the pieces that we have to think about. When we think about where we roll in this interprofessional group.

17:08

We may be the leader. We may be the follower, and it's all based on how we've built these relationships with each other. So I'm the first one out to my athlete. Probably gonna be my team physician. Probably gonna be any other medical providers.

17:21

I'm the first one out there. I'm the leader. But now I know that more advanced skills need to to happen. How can I start to transition to others? And maybe I become a follower and I support them in what they do.

17:36

Put your egos and attitude aside as we start to build this interprofessional team. So that we're ready to provide the best patient center care that we can provide for these athletes. Sometimes you'll hear it as the the school bus theory. I don't need to be the smartest one on the school bus. I need to have the smartest school bus.

17:56

So I need to fill my bus with as many good people who can help with training, help with with with skills, and help intervene when the time comes. So let's put this team together. The first thing we do, no matter whether they've got equipment or not, we have to be able to Identify these critical life threats, make our primary assessment, and think about the airway. Is it open? Do we have a good airway?

18:22

Is it occluded? Are they breathing? If they're not breathing, where do I need to intervene? So do I need to intervene and I need to open and secure their airway, or do I just need to intervene and provide them with oxygen and ventilation assistance that obviously we're quickly looking at circulation? Do they have a pulse, and how quickly do I need to administer CPR?

18:45

If I'm administering CPR, how quickly can I get the defibrillator on? So now I've gotta start getting equipment out of the way. I've gotta be able to expose the chest. Maybe I'm gonna take the helmet off or maybe I'm just gonna take the the face mask off. That's gonna be a decision that we make when we quickly identify how involved this scenario is gonna be.

19:04

If I've got a routine spinal immobilization, maybe just taking the the face mask off is a good solution, just so I have access if I were to need it. But if I've got to do full CPR and all the equipment's coming off anyway, why am I gonna spend time just taking the face mask off to shortly thereafter take the helmet off? We know in football particularly, helmet comes off, shoulder pads come off. They've gotta come off in unison or fairly soon thereafter because of the position that that's gonna place our patient in that extended hyper hyper extended or sniffing position, and it also, you know, has cervical spine complications. So let's think about all of these things.

19:44

Activate our e r e m e a p. Get EMS coming or get them coming out on the field. And then think about what other parts of our EAP have to be managed. We as athletic trainers are probably our our own worst enemy. We wanna do everything.

19:59

We wanna guide all of these pieces. When you're in an emergency situation, particularly airway management and CPR, stay focused on your task. Have an EAP that's going to delineate who does what and have a team leader that's going to oversee that that isn't necessarily providing this emergency care. So this this triangle meets up around the around the patient, and then we can provide good care in each of these positions. We're not overlapping each other.

20:29

We're not conflicting with each other. Everybody's got a role. Everybody's got a position. So we know who's gonna be doing equipment removal. Who's gonna secure the airway?

20:38

Who's gonna be doing chest compressions? Who's gonna start with the AED when it arrives? How is ALS paramedic EMS involvement, how are they gonna filter in so that we can have a smooth transition? Think about all of those pieces as we get there. And that last piece I think is really important and we don't talk about enough as that team leader, that oversight.

20:60

We're all familiar with pit crew concepts of CPR, And everybody's gotta That's my little wake up for you. Get everybody jumping again. Everybody's got a role. You know, they can put fuel in and change to irons on formula 1 in, like, 13 seconds or 12 seconds. But there's also that team leader up overhead.

21:25

Not one of the guys on the brakes, not one of the guys on the tires, not even the crew chief that's right there in the pit area. They've got spotters up ahead. They've got people who are seeing the whole situation and the whole event. Think about that role as we provide this care in these hectic chaotic situation. Somebody that's not immediately involved, they can help lead everything.

21:49

And it comes with practice. So we all know if it's predictable, it's manageable. So let's take a firefighter. You're you're you're covering your local fire department, You're out at a training firefighter goes into cardiac arrest. How do you get their equipment off?

22:05

Practice and planning. About 10 seconds in, they're already on the chest. They're continuing to open his jacket. Great move. Pull her out.

22:21

Look how quickly they get the Lucas device on. Everything's in place, and now the Lucas would be starting compressions right about now. So they had a momentary pause. Alright? It's predictable.

22:35

It's manageable. We can all predict in the fire service that somebody may go into cardiac arrest, full SCBA, full protective gear. How quickly can we get the athlete or the patient into a position where we can do good CPR. So that's a that's a hell of a case, and that's great practice. That's great training, and you see the time.

22:56

This wasn't just slow and easy. This wasn't smoking and joking. This was a legit How can we do this as quick as possible? So what do we need to do? Alright.

23:06

No matter what the equipment is and how it's in our way, we need to be able to expose and access act, access, vital life functions, to establish what we need to do. So we have benchmarks that we know we need to be able to obtain, whether it's it's good hard CPR, checking pulse in less than 10 seconds, AED placement, good bag valve mask ventilations. That's our goal. Those are the things that we need to do. So we have identified what our threats are.

23:40

Now we need to identify how to manage them. And what equipment is in the way to prevent us from adequately doing that. BBM ventilation probably one of the first things that we're gonna do. It's a vital skill to be able to administer good high quality oxygen to administer high volume and high concentration of oxygen. We don't wanna do mouth to mouth if we don't have to.

24:07

We're giving them about 16% oxygen. Let's quickly be able to set up our BBM, get that equipment in place, and use 1 or 2 manbag valve mask ventilations and get good. So I love this picture because it shows how involved your hands need to be. Everybody says, oh, I'm just gonna take face mask off a football helmet, and I can do everything I need to do. Your your mastoid cups, your your patting along the all all of those pieces are going to get in your way.

24:38

So at some point to get a good CNE clamp, you're going to need to take their mask off. Or their their helmet off. We know with football, hockey, lacrosse. There's different considerations. Most of the time, we're gonna take the helmet off either way.

24:56

But now what can we do? So let's before we get too involved in just the the the equipment, let's look at oral Ferrengeal airway. Probably our second line. Can't have a gag reflex. Helps to hold the tongue off the posterior ear farynx.

25:11

And you can go into how to measure it in some of the indications. You know, they can't have a gag reflex. Most of our athletes will still have a gag reflex So this isn't going to work as well for us unless they're in prolonged respiratory failure. Maybe a prolonged overdose, maybe cardiac arrest, Those would be the 2. A lot of our head injuries will also be clinched down, so we won't be able to access them through an oral fair and deal airway.

25:36

Nasopharyngeal is really great back up to that or another option to that. They typically are unresponsive. They may have a little bit of a gag reflex once you place this. They typically tolerate it really well. Even if they have a clenched tooth, we can still, you know, go go about inserting a nasopharyngeal airway.

25:57

The nice thing is, you know, they they may still have some level of of They gag reflex. The downfall is. We don't want them to have major major facial fractures or other facial injuries. As we get into a prolonged respiratory failure, we don't have to go down this continuum, but maybe our bag valve mask ventilations aren't working Maybe our OPAs and our NPAs, we either can't play, so they're not working. Now we look at our supraglottic airways.

26:27

Another airway that is well into the skills and then the KD standards, and it is named in a lot of our position statements. But how do we get here to this? You don't have to follow the continuum. You can jump right to a certain intervention, and we're seeing a lot of EMS and cardiac arrest not trying to innovate. But just trying to put it in a supraglottic airway.

26:48

So contraindications is still a gag reflex, still at risk of aspiration. That's why we don't wanna put it if they've ingestic caustic substances, but ideally none of our football players or or other athletes are in domestic caustic substances. We know the goal line scares a lot of some of our athletes, but, you know, they can get over that. So let's let's measure it. Let's get it in place.

27:09

Let's let's put it in. Cardiac arrest or, you know, irreversible respiratory arrest, like an overdose or a hypoglycemic that we can't treat and alter their sugars really quickly, those are gonna be patients that now we can consider a more advanced airway. Which one, if you're gonna go and get a a superglotic airway, figure out what your local EMS is using. Get something that they're using. It's gonna make ease of training.

27:34

It's gonna make things hacked a lot better. How to insert them, and that's something that you're gonna go through. I'm gonna jump through a couple of these slides. Those are things. Those are the trainings that you're gonna get when you look at what piece I have, what piece I'm getting.

27:50

But, really, they're sitting in the glottic opening so that they are they're blocking the glottic opening right down here at the bottom, and they allow us to get good ventilations no matter where we're positioning, where we're moving our athletes and and how we're going. So who is responsible for the airway? Obviously, we as athletic trainers as the initial responders, we're gonna be that first person that is that is gonna be managing the airway. The quicker we can identify what those issues with airway are, the quicker we can intervene and maybe prevent them from going down that cascade and getting worse and worse and worse. Supplemental oxygen is another great feature.

28:31

A lot of athletic trainers are a little bit concerned, maybe there's Practice Act limitations as well. But just giving them supplemental oxygen can sort of help knock the cobwebs off our our head injuries can do a little bit of pain management, can give you give them a sense that you're trying to intervene and and help them. Anytime we have airway considerations also consider what you're using for suction. Whether it's a 60 cc syringe and an nasopharyngeal airway that I can create a suction, or a turkey baster at the bottom, they work phenomenal. If not, let's get a commercial device, whether it's battery operated or whether it's it's handheld and mechanical, we wanna provide this suction to be able to open that airway up.

29:16

So now what's what are issues do we have with equipment? Chin straps, PBMs, how do they impact us? Let's look at the research. Mihalik in 16, Bowman in 18, they talked about how we are not able to adequately deliver good ventilation with good title volume with chin straps in place. And helmets in place.

29:41

So we know that the chin strap is going to pull up and in on the chin. It holds the helmet down and in place. So just being able to manually open the airway, the chin strap is gonna interfere and it's gonna interfere with the right angles to proper BBM use. So we need to get these things out of the way. We have we cannot think that just providing a open access through the face mask is gonna be our best choice.

30:06

There are times that a supraglotic airway may assist us. So we may not have to take the whole helmet and chin strap off if I can open up their their lower jaw, separate their their mandible and maxilla enough that I can get through the teeth and place a supraglottic airway. So that's something to consider as we consider more advanced airways, but we know that there's those risks with them being clinched or with them still having a gag reflex. So when we just talk about straight BBM, we're going to need to remove the chin strap. Now as soon as that we we remove the chin strap, Now we have the issues that the head is free to move within the helmet.

30:51

So now we can effectively immobilize the head and neck. If they're in a helmet, that we have compromised by taking off the chin strap, removing the face mask. Those are pieces. So we have to really think about what steps are we gonna take to allow us to provide good VVM access, to progress to our more advanced airways, and get the helmet off. So this is the time that I'm gonna say is you may not want to spend too much time just removing a face mask.

31:22

And are more critically injured athletes that we wanna take the whole helmet off. We want to be able to deliver good volume good ventilation, good depth, and good adequate air, and those are all going to be challenged. Now in a more advanced position where A laryngeal mask airway, a supraglottic airway can be placed, or an endotracheal tube can be placed. There is some success even with equipment in place. But I'll tell you particularly now that we're getting into video laryngoscopes, they have a bigger screen on them and a hyperregulated blade, they the the chest plate gets in the in the way with a lot of different pieces of protective gear from hockey, lacrosse, football shoulder pads, all of those.

32:10

Lacrosse is probably the thinnest and we can get away with it a little bit easier. So not only are we talking about can we pass that tube, but does our equipment still fit and fit appropriately. You need experience because with the limitations that a helmet's gonna put in in place, less experienced EMS provider is gonna struggle more, and you can see that there in the graph, you know, where some of the failures were. So continue on as looking at these these issues. We know that a helmet at minimum, we need to get the face mask off And ideally, we need to get the chin strap off.

32:50

That then raises the concern of how how secure is the head within the helmet. And in those cases, we definitely want to take the helm at all. So Gems Journal of EMS did did has done a number of different studies and looked at it that couple of articles, and it is possible to a place to place a supraglotic or to innovate a patient you know, with with that equipment in place. I'd be remiss if I didn't talk a little bit about ventilations and also CPR. With equipment and how they affect because a lot of times for us, we're doing our our airway management on our cardiac arrest cases.

33:29

So you know, face mask removed, chin strap in place, still have that decreased volume, still have that decreased in optimal ventilation, the helmet or the chin strap needs to be removed and the helmet therefore is removed also. So you look at these peak numbers and these peak volumes and it is really a challenge in all the different types of equipment. Hockey, Gins Drafts, a little bit different than football and lacrosse. So that's not gonna pull up on us, but now we get into that issue. Is is it secure?

33:60

And can I get the face mask off? The higher levels that face mask is That eye shield is is more secure. The lower levels, we can start to remove that. But in order to get the chin strap off, we're gonna release the the face mask or excuse me, in order to get the face mask off, we're gonna release the chin strap, which then comes into secondary issues with inline stabilization. So we need to be prepared and ready.

34:25

If we identify that there is a critical intervention that we have provide it good adequate interventions. So look at this. Every piece of equipment is in place right up under the throat. So now we have direct Laryngeal trauma. Directly, laryngial trauma is gonna add some other issues to our our situation because the anatomical structures may be different.

34:56

So really have to think about is what was that mechanism? Did they take a ball to the throat? Did they take a weight bar? Because they were in doing bench press and it struck their throat. Now it's not the equipment that is hindering us.

35:11

It's the equipment that has caused anatomical differences. And blind insertion devices like a supraglotic airway may not be beneficial because we don't have normal anatomy. So the the tongue may be displaced, the esophagus, the trachea r disrupt it, There may be holes, there may be all kinds of issues. So really go back and think about the mechanism and what happened with this. Just taking off his face mask, maybe taking off of his chest plate allows us to provide some care.

35:42

But if we're not getting the response from our oxygen administrator, and our airway adjuncts. It's because that they that direct trauma that caused them problems. So how does it affect chest how does chest how does equipment affect chest compressions? Can you tell it's Friday and I've worked for night shifts? I can't even speak right.

36:06

So we do see a a a decrease in depth of compression and a greater decrease in full recoil in athletes that are wearing shoulder plaids. Football particularly again because of that size and the thickness both in the front and the back. We are not getting the adequate compression. And we're also not getting adequate recoil. Then we add in the airway component and we know that they need to have the helmet and shoulder pads both removed.

36:39

There's some differences in these studies because a lot of them are looking at mannequins. And so the subtleties of the mannequin will will make it challenging, but we haven't found anybody that's gonna let us let us put them into cardiac arrest while wearing football equipment. So that we can test this too too much on on real humans. But let's look at, can we get on to the shoulder pads can we slay them and at least open up and get chest access? And therefore, can we also get the AED in place?

37:09

So we do know that there are limitations to CPR. Doesn't mean don't start it. Verse 1 out may go up under the chest protection, whether it's shoulder pads or other sports, field hockey, lacrosse, ice hockey goalies, things like that. Get up under the chest and start compressions as quick as you can. Now our next providers coming in, they can start to do the tea cuts over the jersey, they can get the shoulder pads removed, they can get the helmet removed.

37:38

Remember in a witness cardiac arrest, Our top priority is adequate, high quality compressions. It is not necessarily Airway management in that first 30 seconds minute, maybe even 2 minutes. Because they should have adequate air wet air in their in their system to support that for the first couple of minutes. So let's get in and get good compressions. Let's get the AED on as quick as we can.

38:06

As we're getting equipment off, now we take a natural break of our compressions, we remove all the equipment, and we get more in engaged in both compressions and airway management. So, again, depth of recoil. Depth of compression and recoil all are are hindered. In lacrosse pads and in, you know, football pads. So what are we thinking about?

38:30

We we talk about can we do a good BVM ventilation? Probably not with helmets and the equipment in place. Can we do good chest compressions? Not if we're losing depth of compression, not if we're losing recoil. So what do we have to think about?

38:44

We have to think about who's on our sidelines. Are they ALS or BLS from an EMS standpoint? Can they go right to a supraglotic airway or a more advanced intubation? If your physician's there, when was the last time your physician innovated somebody? If they're not an ER trauma physician, that probably was a long time ago.

39:03

Even our surgeons don't innovate because they they let anesthesiology do it. What's our patient status? How critical are they? Are they breathing? Do they have an airway?

39:13

Was it trauma, or is it some other event that has caused that like an overdose or cardiac. So now let's look at their equipment. Are they wearing full equipment? Helmet, shoulder pads, are they a specialty athlete? Are lacrosse goalies?

39:32

Are field hockey or ice hockey goalies? Our soccer our our baseball softball catchers. All of those are going to have specialized equipment that we have to be very comfortable with because we know it's going to hinder our ability to put their airway in the right spot. Maybe access the chin, the face, and get a good CE clamp around them to provide good BVM ventilation. Because the truth of the matter is is us in athletics.

39:58

We're typically going to be engaged in BVM ventilations before we've gotten to more advanced airways. Unless we're highly trained and ready, you know, for this. So what devices do we have? Do you carry a supraglotic airway, an eye gel, an king tube or you're relying on EMS to come in. So when that device becomes available, now we can think about how we're going to manage.

40:24

Like we said, a a supraglotic or an intubation may allow the helmet to stay in place, but any of the the the more initial airways, VVM, OPAs, MPAs, they're going to rely on full access to where we are. Are we using mechanical CPR and and and things like that? So circulation airway breathing, that always stays top priority. Now we make the decision of when do we take that equipment off. So if we've got a stable patient, we can do that access to airway prior to transport no matter how stable or critical they are, if we haven't already done it.

41:04

We and the athletics As athletic trainers and and sideline care, we are probably the most proficient at removing helmets face masks, shoulder pads. Let's think about when we do this. Do we do this prior to spinal immobilization? Can we adequately immobilize them on the board? Our our skiers, our BMX, they're all wearing turtle shells right along their back, that is gonna raise their spine off the table, and they're gonna make them like a boat on land where they they they will rock and roll to both sides.

41:38

Now we have to do extra padding if I get those back braces off. So know what your athletes are wearing. Know who's got the tools. Does everybody carry them? Do some people carry them?

41:48

Where are we at? To be able to remove the face mask and other equipment. And really interesting experience with a couple of the NFL teams, Part of their field response emergency action plan is one of their equipment managers comes out. If there's anybody that's trained, at how to take equipment on and off. It's gonna be our equipment managers.

42:09

So let's think about, can they come out? Are they on your sidelines? Can they come out and intervene really quickly give us a chance to focus on other interventions while they get equipment, you know, in position. Certainly, anybody can cut equipment. But if we're looking at just face mask removal and other pieces like that, so we have to weigh all these factors and we have to make a really educated decision on when it's going to happen because there's no always endeavors.

42:34

There's no black and white. Everything that we do is gray. So we may or may not. We may wanna do it on the sidelines. We may not wanna do it on the sidelines.

42:43

Jumbotron Medicine in front of a hundred thousand people maybe we're gonna package them, get them into the tunnel. Now we can start to repackage them, get some of that equipment off when we don't have all that all all the fans watching and and, you know, 10000 cameras on us. So be ready for those situations. But we also have to do patient center care and do the right things for the right reasons. So, again, focus on on on airway management, focus on good compressions, and let's evaluate what pieces are in our way.

43:15

Helmet and shoulder pads, we've deemed are really must be removed. Early on in that process to provide good adequate care. We can immobilize them. We can provide some c Spine. Protection, but it's gonna make it more challenging.

43:34

So really put the right people in the right place, the right time, You know, think about the athlete size. If we're doing mechanical CPR, obviously, we know their their chest and their shoulder pads has to be removed in order to get good mechanical CPR in there. And what's their condition? Are they progressively getting worse? Or are they more stable?

43:55

That's gonna help us whether we just take the mask off or whether we take all the, you know, helmets and shoulder pads off. So there's kinda 22 rules of thinking. Only remove what's in the way of us doing our critical care. So can we get a good carotid pulse? Can I do good airway?

44:15

Can I do good breathing? Can I do good chest compressions? If they're not hindering any of those, then we leave it in place. Or the other side is, I remove everything as soon as I as soon as it's appropriate and when we get when we get the right resources available. Truly, it should only take us about 30 to 45 seconds to get all the equipment off and out of the way.

44:40

We could be doing chest compressions while We're doing some of that equipment removal, but it's gonna have an impact. The last variable is always the weather. And how long they're going to be outside? Do I wanna fully expose the chest in the body, put them into hypothermia while waiting 15 or 20 minutes for EMS to arrive? If I'm doing CPR, of course.

45:03

If I don't have good airway interventions, of course. But if I'm in a more stable environment, maybe this isn't the time to take those off. It really comes down to how well and what you've done in practice. Little tidbits just as we finish up is, you know, looking at good clear communication when you go to take equipment off. So that we don't do any excess motion, you know, that the helmet's clear, that the oxapunt, that the helmet's clear, the ears, that, you know, whoever's taking SeaSpine may feel a little jarring there.

45:36

We wanna minimize that. Our lifts, our rolls, all of those pieces we really need to practice on. So we've done some work with extreme simulations. They've got a great quote that I love. Your first time should always feel like your second time.

45:52

So that comes again back to good training, a good approach, so that when you see this in real life on the sidelines, you're like, oh, yeah. We've done this. We've already done this before. So build a good team. Remember the roles that you're gonna play may may vary as the initial responder, as the primary caregiver, until more personnel arrive, you're the leader.

46:15

But as other people arrive, you may find yourself in different roles and you may find yourself back and forth between a leader and a follower in in different situations. So get a good team, get a good interprofessional, practice collaboration and going, and leave your ego at the door. So I may be able to do airway. But if I've got a guy with me that has done it, 10000 times more than I have, maybe they're the right person to do it. Or the other way around, I feel like I'm the most qualified I need to get into a role that I can provide this care for.

46:48

When you're practicing, practice under stress. Create a stressful environment. That will allow you to provide the care that you need in a time of stress, in a time of high exertion, in a time that your heart rates up, your fine motor skills have changed, and be ready. And then know what is best for that athlete at that moment and weigh all of these factors to make the best decision that is going to be just because your EAP says you should or you shouldn't doesn't mean that that is the perfect time to do it. Be ready for all these factors and be able to justify why you did what you did.

47:30

We talked about this earlier. It's worth repeating again. And times of stress, you will fall to the level of your training, not rise to the level of your expectation. So make a point to create a good realistic training. My big thing is don't practice till you get it right.

47:46

Practice until you can't get it wrong. So go through this multiple times, different weather, different times of day, day, daylight night times upside down in a bus because it just crashed. While you were driving home. You we notoriously do things until we get it right once. We said, oh, yeah.

48:05

That was great. We did it right. Don't do it until you do it. Got it right. Do it until you can't get it wrong.

48:14

What do we got for questions?

48:17

Jump back on here. Ed, he did not disappoint. I'm just gonna tell you that right now. You know, this is you know, just a couple of things that kinda come to mind. I know and some questions come through is, you know, you talk about the being predictability and manageability.

48:33

And I think it's important people that everyone understand that you can't predict everything that occurs it just gets a determined response. You're you're if you go on to the field, I think you've created did a great job of this. It's, like, for example, the equipment laid in athlete, you can expect at one point of time there is going to be an airway issue, and it may not be, you know, you look at the case of Denny Kelleyton with the the more handling case. From my understanding, that was his first time to ever actually done CPR. Not just him, but some some other group, but him physically doing CPR.

49:08

We're assisting in a team effort in 30 something years. And somebody asks, have you ever done this or not? So that and then just remember practice makes permanence of practice right. You know? Those are things are really home and and, you know, whatever you do, you better have your protocol and and practice it protocol.

49:26

That's a really think you hit on some great points there. Any questions for anybody there? I know we've got got a couple minutes left or if you wanna ask a question. We've got a little queue in it. Here, we got one coming in right now.

49:41

Xavion has here's one is I have an athlete with an internal chest plate. His medical alert bracelet says he requires deeper compressions. How deep is deeper?

49:54

It's hard to say exactly. I don't know that you know, what exactly how size how big that plate is. You know? So I would meet with their physician, talk to their physician, and see if if, you know, the manufacturer has some guidelines on that. I would anticipate that, you know, we're trying to get about half the chest compression, so it's gonna be deeper and that you have to press harder to get there.

50:19

Because that internal chest plate is going to, you know, effectively be more aggressive than the ribs, and we're trying to compress the heart that's underneath it. So deeper being, it's gonna be harder, it's gonna be, you know, a more aggressive push, but we still have to do that adequate depth of compression even with the plate. So I would think the depth is still gonna be the same. But what force and mechanism it takes to get there is what's gonna need to be deeper?

50:51

Great question. Open on the we'll have a couple of more come in. So I have a question kind of a change gears for a second. In the training that you perform, and I I know you work with a lot of different providers coming in different settings. How much is spent or the importance of having one of the personnel just actually leave the simulation, not be there managing the situation and not do it being hands on.

51:19

Like, the 3rd person doing see you know, if you had a 4th person, they're managing that in what impact have you seen that on the overall effectiveness of the provider who actually is not they used to be putting hands on, but just stepping back and having to manage that situation.

51:36

Yep. A 100%. So the American Heart went into a team lead, situation with with cardiac arrest and ACLS. You know, we get talking. Think about, you know, football on the sidelines.

51:47

You still got that spot or up above that is helping guide and direct and and anticipate future moves because the coach on the sidelines and the quarterback in the Huddl don't see everything. So as we transition into a leadership role, and that can play in a different a couple of different aspects, either one of your senior providers, even if they're doing care, they start to rotate out and then become the, you know, the the oversight, that team lead, or later on, you know, as more providers come in and we've we've expanded our response. Now one of those later providers stays back, stays hands off, and starts to dictate all the care. Where is the cart coming from? Which direction is the cart facing?

52:32

Is the spine board available? Have we taken all the straps off of it? All of these little pieces that are gonna impact our care? But aren't in the immediate intervention. So I think if you can get that team lead person, in a scenario, it's going to be a game changer for you, particularly in our bigger scenarios.

52:57

It's a challenge for our high school athletic trainers that may just be 1 or 2, but maybe the team lead is the coach. Where they're not necessarily the best care provider, but they can see what's happening and they know where things are gonna go and and how things are gonna progress. But we push that a lot having that team lead concept, whether it's, you know, pit crew concepts and your spotter on the top of the the turn for or whether it's football thinking about your offensive coordinator sitting up in the box up ahead really changes the dynamics Because when you're hands on neck deep in this scenario, you can't be managing the 101 things that need to be happening around you. And that's where we as athletic trainer struggle because we wanna do a lot, and we need to focus on that critical intervention that we're providing.

53:48

So probably the the biggest I know you see this lot is in crowd control, is or they're seeing control. An SNL, I know know how you know, we've both been through, you know, several on the call who are attending or or EMS trained is that's, you know, learn the scene control That's the most you know, the as you said earlier, comma is contagious, but just managing the scene, get the extraneous factors out of the way because of somebody, you know, with that. So working through the process or having somebody who does that, that's Yep. An excellent point you brought up by having a coach or just having having that scripted out where even the like, a high school and athletic administrator, they're the ones controlling what's gonna happen. And let let They just take that one more one thing off the plate that doesn't have to occur with the scene as well.

54:33

54:34

Yep. For sure.

54:35

Great. Great. Great question there. Any other questions? We got time for about a couple more minutes or any other question we have and with that.

54:44

What is We have in other words coming in other words, other words coming through here. What is the the in your like, some of the equipment you have. Like, I know you do a skiing, which is different, or you may have, like, rodeo, for example. I know they have a flat jacket that comes in. You know, they They have a very different process.

55:03

You're still having to address that that the head head position with that equipment. And I think the one thing was You brought forth, and those who brought forth earlier in the week with Doctor. Oordiski and and also with Ron on this an Airwave Spine Management. Is making sure if you can remove the helmet. Whatever you gotta do, you gotta deal with the air airway.

55:22

You're gonna have to do it regardless. It's whether you push it down the line, And when you remove the helmet, it's just fine. If you get the shoulder pads on, you said having make sure you can get the compressions adequately and have the air away. But if you do just put a block you know, a towel or do something, you're you're keeping the head neutral where it was, and then you can find you can mobilize them. Or spine motion restriction.

55:44

So that's a I just wanna reiterate that. I think that's probably one of the it's another point you've got.

55:49

About what your end goal is and how how can you get We can get there a couple of different ways, but our end goal is adequate airway access, good inline cervical spinal, immobilization, and adequately immobilizing them on some sort of a transfer device, whether it's a scoop stretcher or a spine board, and know what your athletes are wearing. Know what helmets are out there. It's one thing in the college and the professional setting where every helmet's the same, but maybe for day of practice, you go around and you walk through and you see what all your cross players are wearing. Are they wearing cascade? Are they wearing last year's model?

56:26

Are they wearing this year's model? What are they wearing so that you're really comfortable with with all of that equipment? Ski boots and and back protectors, motocross, As you said, rodeo, all of them are gonna have some sort of unique equipment. So be ready for it, and don't hesitate to ask them and talk to them about it.

56:50

Okay. As a I'm a throw another question actually. So as a young if you have a thinking of the young provider you work with, like, around EMS as well, and that's no different. There would be a young athletic trainer They're they've no skills, but trying to you see those things as different situations to come up. What do you what has been the biggest or the most significant small thing that that they have done to really impact how they improve their training.

57:19

Practice. Don't sit still. Practice every day. Try to learn something new. Everyday.

57:25

Try to practice something. You know, if you're new to football, lay all your freshman down on every five yards, you and your coaches go through. They gotta take their equipment off the end of practice anyway. Now I can go through and I can practice 10 helmets and shoulder pads remot removals. You know?

57:42

And and I could do that once a week. Every Friday after practice, that's you know, that's kinda what we do. Same thing is is, you know, if you don't have the equipment, meet with your local EMS and practice. Set that up. This isn't just August 1 time free season.

57:57

They need CEUs. You need CEUs practice. Just practice. We we fall into. I'm tired.

58:04

I'm hungry. I've got a long day. I've got paperwork to do. I've got a document. 10,000 athletes.

58:11

You know? And we we let practice fall by the wayside. And if you can keep that as a higher priority, weekly, monthly, whatever the case may be, a journal club, a discussion group, even some of these discussion boards that are out Discord and some other, you know, some great resources out there on Facebook and otherwise. Now ask and think so that you can just train your thinking until you get your skills practice.

58:39

And that may be the best time to do the training is when you are tired because you're I mean, you're gonna pick out something that really is, you know, if you're if you're if you're I think goes back to what you said. If you're if you're trained well, you're gonna do it well when you're mentally you're you're you're, you know, early in the first part of the shift or your or your work shift. Versus 10 hours later, you're gonna perform it. It goes back to your your practice habits, and you've trained that that training becomes an embedded process. So I think that's a sure.

59:09

How many of us do spinal injury management practice in November in the rain? Nope. You know, not unless you're starting basketball season. But most of our our outdoor sports, they're like, at the end of the season, I'm not doing it, but your hands are cold, your tired, your gloves are on, your your hats on, and Everything's a little bit different. We're in your big sideline puffy coat.

59:30

Now you can't practice in the environment that

59:33

you're We don't have that cold weather down here. We just have just we're you know, it's we we're sure we don't float float away at the time.

59:41

So Yeah. For sure. I'll bring you up to Maine. We'll we'll go to 36 below and and really try some some equipment removal.

59:48

I will gladly sit inside. I think we'll see you do that as well. Hey, Scott. And thank you again so much. We're up on the 1 o'clock the the hour time block.

59:58

Again, everyone, provide your feedback on the value equation instruments that you'll be sending out, and it was fantastic having you here. You've got Ed's contact information up there. Also, for Sports Medicine Emergency Management, you can reach out to them as well. You all do some fantastic work, and I'm

1:00:16

Thanks.

1:00:16

Think, well, that you had the opportunity where I could get you on board to to be here today. Thanks again.

1:00:21

Glad to be here. Thanks, everyone. And if you got any questions, let me know.

1:00:26

Have a great day. Thank you.

1:00:27

You too. Take care.