Emergency Situation

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Countless young athletes are taking the field without a trained care provider on the sideline, but new efforts to equip coaches with basic first-aid knowledge are coming to the rescue

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As those at the National Center for Sports Safety frequently point out, parents wouldn't think of dropping their children off at a public swimming pool that didn't have a certified lifeguard on duty. Yet, those same parents often don't give a second thought to leaving the kids in the hands of a soccer coach who may or - more likely - may not know the first thing about administering first aid.

It's a potentially dangerous situation that NCSS officials and others are working in earnest to remedy. "We use the public pool analogy as the best representation we can think of in terms of what we would ideally like for every single park, gymnasium and field in the country," says April Morin, executive director of the NCSS, a nonprofit foundation established in January 2001 to develop and deliver safety curricula to coaches of high school and youth sports. "We're now trying to finalize what we feel the safety requirements at different levels should be."

That determination, expected by year's end, is the result of the first "Setting the Standard Summit," a three-day brainstorm involving representatives of the medical, sports and emergency-response fields held in August 2002 in the NCSS's hometown of Birmingham, Ala. The ambitious task of getting basic first-aid knowledge and tools into the heads and hands of coaches began by paring down a 4-inch-thick three-ring binder of comprehensive first-aid procedures into a manageable number of fundamental do's and don'ts that coaches could be taught in less than three hours. (By comparison, the Sports Safety Training program available through the American Red Cross and the U.S. Olympic Committee requires six and a half hours to complete.)

"What we wanted to do was put together a curriculum that specifically targeted mom or dad volunteer coaches - individuals who are working full time and barely get their clothes changed to get out to the field for practice." Morin says. "They need some basic sports safety training information to recognize an emergency situation and then know what to do and what not to do until professional help gets there. We do not want to train a mom or dad how to fix a dislocated shoulder. What we would like is to have them recognize a dislocated shoulder and then call 911."

If it's not yet a full-scale emergency, the lack of competent medical care for participants of high school and youth sports remains a critical situation in the minds of many. According to figures gleaned from a variety of sources, a record 6.8 million athletes currently compete at the high school level in the United States, but only a third of those coaching them have had any type of coaching education, much less first-aid training. Meanwhile, an estimated 52 million participants fill the nation's youth sports programs and competitive leagues, though only one in 10 coaches among the 2.5 million volunteers guiding America's kids through games and practices possesses coaching education of any kind.

To date, the NCSS has trained some 3,000 coaches in the basics of first aid in Alabama, at least four of whom claim skills learned during the training helped them save a life. In July 2002, the NCSS successfully lobbied the Alabama High School Athletic Association to mandate that all coaches in the state carry a valid CPR card. At the time, only nine other state high school activity associations could claim a similar requirement. "Ohio requires all coaches to have CPR and sport first aid training every three years, and there are a number of states like that," says Tim Flannery, an assistant director for the National Federation of State High School Associations. "Some states require that off-staff coaches adhere to more requirements than coaches who are certified teachers. It's very complex in this country. We are working to try to get all states to have similar requirements regarding first aid and CPR."

It's hard to place one of those two disciplines above the other on a priority list, says Melinda Flegel, an athletic injury specialist at the University of Illinois and author of Sport First Aid, the official text of the American Sport Education Program (ASEP). But, Flegel says, "You're going to see more types of problems requiring administration of first aid than you will CPR. With kids, especially, if you don't handle an injury properly, it could have long-term ramifications."

Much like state high school activity associations, organized youth leagues are fairly hit and miss in terms of first-aid training. Pop Warner Football, for example, states in its rulebook that "In the absence of a specialized trained person affiliated with the team/squad in the medical area (physician, paramedic, specially trained volunteer), one of the coaches must be the holder of a current Red Cross certificate in community CPR and first aid or its equivalent." Little League Baseball, on the other hand, makes no such requirement. "Generally, any such rule would have to require the same training for managers and coaches, as well as umpires, in each of the 105 countries in which Little League is played," says Little League spokesperson Lance Van Auken. "We do have a Manager/Coach Education Program that includes first-aid training, but it is not mandatory. Each local league decides for itself whether or not to implement the program."

Sometimes such decisions hinge on the perception that the necessary time commitment may deter coaches from broadening their safety education. Moreover, many parents volunteer as coaches only as long as their kids are eligible to compete, making first-aid training a near-annual ordeal for youth leagues amid the turnover. The NCSS hopes a streamlined curriculum will help mitigate time-investment concerns on both sides of the training equation. "It's one thing when you're dealing with paid high school coaches; you make that a part of their job description," Morin says. "You typically don't see the words 'volunteer' and 'requirement' go hand in hand."

"A lot of sports organizations have a certain amount of leadership programs that coaches have to go through, and one of the things discussed at the summit is that this is yet another time commitment that we're asking of them. It's hard to keep a coach, because of the time commitments," says Al Green, a former athletic trainer at the Universities of Kentucky and Michigan who represented the National Athletic Trainers Association at the NCSS summit. Adds Flegel, "Even the high school coaches don't like to take that time if they're not going to be reimbursed for it."

Not true, says Richard Ball, a Phoenix-based attorney who in 1988 introduced his own first-aid program, called Basic Amateur Sports Injury Care (BASIC), making the eight-and-a-half-hour course available nationwide and personally teaching it to hundreds of "grateful" (his word) high school and youth sports coaches in Arizona. "Time commitment is an excuse that's commonly given by school administrators, but it's hollow," Ball says. "People come in and offer their services because they want to coach. The amount of time that a person commits to a coaching position is enormous, and to say that they won't give a couple of evenings or a Saturday to learn first aid and CPR is nonsense."

And the risk of not having at least one trained individual at all games and practices far outweighs any inconvenience to coaches, adds Ball, who has defended football helmet manufacturers in dozens of sports injury cases involving school districts. One of those cases, stemming from the paralytic injury of a Missouri high school football player in 1984, is featured in Ball's landmark 1988 video titled "Sports on Trial." The two-hour tape, which is still used in college-level sports management and injury-prevention classes, includes 90 seconds of actual footage showing the injured player lying face-down, being rolled onto his back by teammates and then having his helmet removed by coaches. Whether the athlete's quadriplegia resulted solely from the initial game contact or from the subsequent attention he received was never proven (the case was settled before trial), but it was nonetheless alleged that improper response at least aggravated the athlete's condition.

"That has been an allegation in many cases across the country - many of them not nearly as severe as that one, but others that severe and more," Ball says. "In Phoenix, in 1988, a young man collapsed during a football practice with severe heat illness and was left unattended by coaches for an extended period of time. Finally, a student ran to the athletic training room and summoned the athletic trainer, who then summoned medical aid. The boy died in the middle of the night. The primary allegation of the lawyers for the boy's mother against the school district was the inability of the coaches to recognize and immediately respond to his heat illness. That's all a part of any appropriate, basic first-aid course - prevention of, recognition of and response to heat illness."

One need not look that far back to find that similarly perilous episodes - involving collegiate wrestlers and professional football players, for example - have continued to unfold with unsettling frequency. Following the longstanding lead of professional franchises and college athletic programs, high schools have become increasingly receptive to the concept of employing full-time certified athletic trainers, but those trainers can't be everywhere at once, particularly during after-school practices. Likewise, physicians and paramedics remain a game-day luxury, despite the fact that more than half of all sports injuries occur at practice, according to the NATA. "You'll find that if somebody's there, it's generally going to be in football, at least during games. It's at the other sports, like soccer or softball, that you're not going to have somebody there," says Flegel. "Frankly, even if the kid gets an ankle sprain and it's not taken care of properly, the chances for reinjury are huge, probably at least 50 percent."

"Any injury situation can become worse if it's mishandled. Lawyers have a field day with that," Green says. "Unfortunately, we quite often see - especially in the heat of battle - that an athlete is injured and the coach, who is untrained or doesn't have any minimal standard of training, says, 'Ah, rub a little dirt on it. You'll be fine. Get up and get back in there.' It may, in fact, be a significant injury."

As the St. Louis Rams proved in week one of the NFL season, even professionals at the highest levels of sport are not above botching an occasional injury diagnosis. Early in the first quarter of the Rams' season opening loss to the New York Giants, quarterback Kurt Warner suffered a concussion that would go undetected despite Warner exhausting his team's first-half timeouts amid play-calling confusion and fumbling six times before game's end. One can safely assume that such misguided injury assessments are taking place with some regularity on high school and youth sports fields where no one trained in first aid is present. "Sometimes you have to protect the athletes from themselves," says Green. "And when that athlete says, 'I'm OK,' a coach who's not trained or has minimal knowledge is going to go with what the athlete says."

Conversely, lack of first-aid knowledge can also lead to overreaction. "It's not unusual to be called to a youth-league sporting event because somebody has this 'awful fracture,' " says Green, a volunteer firefighter and EMT. "Especially when you're dealing with younger kids, the injury occurs and there's a lot of screaming and hollering. Someone says, 'Oh, my gosh, dial 911.' And you get there and it's a minor sprain or a minor bruise that anyone with some training would be able to recognize. Meanwhile, they've tied up an ambulance and fire truck for a very minor situation. That happens all the time."

If organizations such as the NCSS, the ASEP and the NFHS have their way, coaches incapable of properly responding to player injuries will one day disappear completely from the sidelines. Beginning in February, the NFHS will make available online first-aid training based on the ASEP course authored by Flegel, whose third edition of Sport First Aid is due out that same month. "Currently, we deliver 40,000 courses a year; we need to be doing closer to 200,000 courses a year," Flannery says.

The NCSS looks to go online with its first-aid training early next year, as well, but the group will continue to offer in-class sessions, "so people always have an option and there's not an excuse for why a coach didn't get educated," Morin says. The latter delivery model may involve a nationwide network of 15 physicians as instructors, but firefighters may also be recruited in that capacity, putting first-aid training within the reach of coaches in every community that has a fire department. Both online courses eventually will expand their baseline first-aid instruction into sport-specific modules, focusing on injury prevention and even athlete nutrition.

The NCSS also envisions securing corporate sponsorship as a means to offer coaches discounted first-aid kits. Moreover, corporate support would allow for the design and distribution of a patch, to be sewn to the caps and jackets of coaches who pass the course, as visual evidence of their first-aid competence. "It goes back to that analogy of a lifeguard. You can physically see the Red Cross emblem on his or her swimwear, and that tells you automatically that that person is qualified to handle the safety of the pool," Morin says. "If parents see something identifiable on a coach, they then can say, 'I feel good about leaving my kids with this coach, because he or she has been trained.' "

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