It looks like fall has officially arrived. In addition to the distinct change of season that we see outside, I’m often amazed at the seasonality of medicine. In the ER, we almost palpably feel a difference in the rhythm of the ER between the seasons. Summer, of course, is overwhelmingly busy. In fall we see a drop in patient volume, but prepare ourselves for hunting trauma, which tends to be primarily falls from height. Winter, of course, brings us cold-related injuries, snowmobile and skiing trauma, as well as the annual influenza surge. Spring tends to be a time to re-coup a bit before the summer onslaught.

I know, both from reviewing runs and from my time working in EMS, that the prehospital setting also has a certain seasonal ebb and flow to it. One of the things that fall brings us, in EMS, is an increase in sports related injuries as young athletes return to school and the fall athletic seasons gets into full swing. As it relates to EMS, football is an important sport to consider. EMS is called upon to standby many of these games as the first responding, and often only, medical personnel at these events. This can be taxing to both EMS schedules, and EMS providers.

Any of us who have even a passing interest in following the news are aware of the increasing coverage devoted to sports related injuries, most notably closed head injuries (concussions). In medicine, our understanding of the pathophysiology and importance of closed head injuries is growing exponentially. As our understanding of these injuries increases, so does the complexity of evaluating and appropriately treating these patients. The guidelines for treating these injuries and, importantly, the guidelines for return to play are ever changing and vary between professional organizations. I won’t go into details regarding the complex evaluation, treatment, and return to play algorithms, in part because they are so complex that I tend to look them up when I need them. And, as regards return to play recommendations, as an ER physician, I am not an expert in this area.

So who is an expert regarding sports-related injuries and return to play recommendations? Well, obviously a Sports Medicine specialist is the gold standard in this area. Certified Athletic Trainers are the sidelines extension of Sports Medicine and also have a strong understanding of these complex issues. Family Medicine doctors are also very well versed in the return to play guidelines and have the ability to follow a patient over time to ensure they are ready to safely return to sports. So, with that in mind, who is not qualified to say whether or not an athlete is capable of safely returning to play? Well, most everybody else is not qualified, including parents of injured athletes and – unfortunately – you as EMS providers. You are clearly well trained to stabilize and transport injured athletes suffering from a wide range of physical insults, from minor to life-threatening. However, you have inadequate training to make an assessment as to whether or not an athlete is safe to return to play. Even if you – as a particular individual – do have training in this area as, say, a coach or athletic trainer, when you are working in EMS you are only approved to work within our specified protocols; none of which relate to returning an athlete to play. This is a very important and specific point…when you are working on an ambulance you are only approved to provide care within the scope of our written protocols. Ultimately, you are providing care under the license of your medical director, who has approved the specific care you can provide under his/her license via your written protocols. You are not covered, or authorized, to provide care or treatment – or recommendations to patients - not within the scope of your protocols. This very clearly includes any recommendations to an athlete regarding their ability to safely return to play.

So what should you do when you are faced with an injured athlete who is anxious (as many of them are) to return to the game? Certainly, your first obligation, as always, is to make sure that a patient is medically stable and to provide any life or limb saving interventions that are needed. Beyond that, your role is limited to providing transport to the hospital so that a physician can formally evaluate the patient. If the patient refuses transport and insists on returning to play, then a refusal form needs to be completed and signed by an appropriate individual…keeping in mind that a minor cannot legally make his/her own medical decisions, nor can a patient who lacks the mental capacity to understand and make an appropriately informed decision (i.e. – a patient with a head injury who has an altered LOC). I understand that this has the potential to put you, as the medical provider, in a difficult position. But that is the nature of medicine. As an EMT, you are routinely placed in difficult situation and expected to make the right decision and nearly 100% of the time you perform admirably. The same high expectations for professional prehospital care exist when you are performing (often mundane) standby duties. Just remember that your training and expertise is in the care and transport of injured patients. Keep in mind where your expertise lies, and don’t allow yourself to be drawn outside the clear guidelines of your training. As always, I know each of you will do a great job. Be safe, have fun and – as always - feel free to direct any questions or concerns to me, whether through this blog, or directly by email.

Keep up the good work.

Dr. Shultz

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