Injury/Illness Quiz 1.3 Law & Ethics Part 2

Implementation :

- 1st - the plan must be committed to writing (Table) to provide a clear response mechanism and to allow for continuity among emergency team members. This can be accomplished by using a flow sheet or an organizational chart. It is also important to have a separate plan or to modify the plan for different athletic venues and for practices and games. Emergency team members, such as the team physician, who are present at games may not necessarily be present at practices. Moreover, the location and type of equipment and com- munication devices may differ among sports, venues, and activity levels. - 2nd is education. It is important to educate all the members of the emergency team regarding the emer- gency plan. All personnel should be familiar with the emergency medical services system that will provide coverage to their venues and include their input in the emergency plan. Each team member, as well as institution or organization administrators, should have a written copy of the emergency plan that provides documentation of his or her roles and responsibilities in emergency situations. A copy of the emergency plan specific to each venue should be posted prominently by the available telephone. - 3rd the emergency plan and procedures have to be rehearsed. This provides team members a chance to maintain their emergency skills at a high level of competency. It also provides an opportunity for athletic trainers and emergency medical personnel to communicate regarding specific policies and procedures in their particular region of practice. This rehearsal can be accomplished through an annual in-service meeting, preferably before the highest-risk sports season (eg, football, ice hockey, lacrosse). Reviews should be undertaken as needed throughout the sports season, because emergency medical procedures and personnel may change.

Confidentiality :

- Most health care codes of ethics support the inviolability of con dentiality except under conditions in which the health care professional judges that the withheld information may result in harm to the patient or someone else. - The operative phrase in this case and in many cases of con dentiality is "signi cant past [or current] medical history" that is relevant to provide. - Certainly, the physician should never tell a coach about a potential student athlete's personal history that has no bearing on his or her ability to perform athletically, if in fact that information was given in con dence. But a physician is under no such obligation of strict con dentiality if, for example, an athlete discloses that he is illegally taking performance- enhancing drugs. This action is directly in violation of rules controlling the use of banned substances, and it moves toward a legal issue taking precedence over any ethical concern about confidentiality. - If an athlete is seeing a private health care professional not employed directly by the team, then the limits of con dentiality are based on the type of information judged by the health care professional that affects the athlete's overall health and welfare to compete.

Background :

- Most injuries sustained during athletics or other physical activity are relatively minor. However, potentially limb-threatening or life-threatening emergencies in athletics and physical activity are unpredictable and occur without warning. - Proper management of these injuries is critical and should be carried out by trained health services personnel to minimize risk to the injured participant. The organization or institution and its personnel can be placed at risk by the lack of an emergency plan, which may be the foundation of a legal claim.

Informed Consent :

- Ultimately, the loyalty of the physician must be toward the wishes of the athlete, despite pressures exerted on the physician to change the athlete's mind. In such a case, the physician must advocate for the most appropriate course of medical treatment given the evidence. If when given full disclosure and informed consent, the athlete decides for a meniscectomy, the physician must weigh the bene ts and risks of doing an alternate procedure based on his or her best judgment. As mentioned above, in the nal analysis the physician has the right to refuse a medical treatment that one judges to be inappropriate. - the physician must obtain full consent of the patient, which requires full knowledge of all aspects of the procedure, including its less proven nature. The physicians themselves must conduct a careful review of the new technology before administration to a patient.

*Ethical Issues in Sports Medicine* An interesting source of pressure is the pressure that team physicians often place on themselves. There are 2 reasons :

- team physicians believe that they are part of the team and therefore sacrifice a player's health for the sake of the team - a team physician may put undue pressure on himself to please management so he or she can keep one's position because of the many benefits received from the status as a professional sports team doctor - The strong pressure creating con icts of interest for the team physician may cause one to compromise one's medical judgment. But as Polsky correctly reminds us, although con icts of interest may increase risks of unethical conduct, they are not inherently unethical but rather a fact of practice reality. Physicians and other health care professionals must always act in the best interest of the patient whether she or he is an athlete or not, regardless of setting, and irrespective of incentives.

*NATAP statement* Objectives :

- to educate athletic trainers and others about the need for emergency planning - to provide guidelines in the development of emergency plans - to advocate documentation of emergency planning.

What is their position statement?

1.) Each institution or organization that sponsors athletic ac- tivities must have a written emergency plan. The emer- gency plan should be comprehensive and practical, yet flexible enough to adapt to any emergency situation. 2.) Emergency plans must be written documents and should be distributed to certified athletic trainers, team and attending physicians, athletic training students, institutional and organizational safety personnel, institutional and or- ganizational administrators, and coaches. The emergency plan should be developed in consultation with local emer- gency medical services personnel. 3.) An emergency plan for athletics identifies the personnel involved in carrying out the emergency plan and outlines the qualifications of those executing the plan. Sports med- icine professionals, officials, and coaches should be trained in automatic external defibrillation, cardiopulmo- nary resuscitation, first aid, and prevention of disease transmission. 4.) The emergency plan should specify the equipment needed to carry out the tasks required in the event of an emergency. In addition, the emergency plan should outline the location of the emergency equipment. Further, the equip- ment available should be appropriate to the level of train- ing of the personnel involved. 5.) Establishment of a clear mechanism for communication to appropriate emergency care service providers and identi- fication of the mode of transportation for the injured par- ticipant are critical elements of an emergency plan. 6.) The emergency plan should be specific to the activity ven- ue. That is, each activity site should have a defined emer- gency plan that is derived from the overall institutional or organizational policies on emergency planning. 7.) Emergency plans should incorporate the emergency care facilities to which the injured individual will be taken. Emergency receiving facilities should be notified in advance of scheduled events and contests. Personnel from the emergency receiving facilities should be included in the development of the emergency plan for the institution or organization. 8.) The emergency plan specifies the necessary documenta- tion supporting the implementation and evaluation of the emergency plan. This documentation should identify re- sponsibility for documenting actions taken during the emergency, evaluation of the emergency response, and in- stitutional personnel training. 9.) The emergency plan should be reviewed and rehearsed annually, although more frequent review and rehearsal may be necessary. The results of these reviews and re- hearsals should be documented and should indicate wheth- er the emergency plan was modified, with further docu- mentation reflecting how the plan was changed. 10.) All personnel involved with the organization and spon- sorship of athletic activities share a professional respon- sibility to provide for the emergency care of an injured person, including the development and implementation of an emergency plan. 11.) All personnel involved with the organization and spon- sorship of athletic activities share a legal duty to develop, implement, and evaluate an emergency plan for all spon- sored athletic activities. 12.) The emergency plan should be reviewed by the adminis- tration and legal counsel of the sponsoring organization or institution.

Documentation :

A written emergency plan should be re- viewed and approved by sports medicine team members and institutions involved. If multiple facilities or sites are to be used, each will require a separate plan. Additional documen- tation should encompass the following : 1. Delineation of the person and/or group responsible for documenting the events of the emergency situation 2. Follow-up documentation on evaluation of response to emergency situation 3. Documentation of regular rehearsal of the emergency plan 4. Documentation of personnel training 5. Documentation of emergency equipment maintenance It is prudent to invest organizational and institutional own- ership in the emergency plan by involving administrators and sport coaches as well as sports medicine personnel in the planning and documentation process. The emergency plan should be reviewed at least annually with all involved personnel. Any revisions or modifications should be reviewed and approved by the personnel involved at all levels of the sponsoring organization or institution and of the responding emergency medical services.

Communication :

Access to a working telephone or other telecommunications device, whether fixed or mobile, should be ensured. The communications system should be checked before each practice or competition to ensure proper working order. A back-up communication plan should be in effect in case the primary communication system fails. A listing of appropriate emergency numbers should be either posted by the communication system or readily available, as well as the street address of the venue and specific directions (cross streets, landmarks, and so on)

Equipment :

All necessary supplemental equipment should be at the site and quickly accessible. Equipment should be in good operating condition, and personnel must be trained in advance to use it properly. Improvements in technology and emergency training require personnel to become familiar with the use of automatic external defibrillators, oxygen, and ad- vanced airways. It is imperative that health professionals and organizational administrators recognize that recent guidelines published by the American Heart Association call for the availability and use of automatic external defibrillators and that defibrillation is considered a component of basic life support. In addition, these guidelines emphasize use of the bag-valve mask in emer- gency resuscitation and the use of emergency oxygen and advanced airways in emergency care. Personnel should consider receiving appropriate training for these devices and should limit use to devices for which they have been trained. To ensure that emergency equipment is in working order, all equipment should be checked on a regular basis. Also, the use of equipment should be regularly rehearsed by emergency personnel, and the emergency equipment that is available should be appropriate for the level of training of the emergency medical providers and the venue.

Legal Need :

Also of significance is the legal basis for the development and application of an emergency plan. It is well known that organizational medical personnel, including certified athletic trainers, have a legal duty as reasonable and prudent professionals to ensure high-quality care of the participants. Of further legal precedence is the accepted standard of care by which allied health professionals are measured. This standard of care provides necessary accountability for the actions of both the practitioners and the governing body that oversees those practitioners. The emergency plan has been cat- egorized as a written document that defines the standard of care required during an emergency situation. Herbert emphasized that well-formulated, adequately written, and periodically rehearsed emergency response protocols are absolutely required by sports medicine programs. Herbert further stated that the absence of an emergency plan frequently is the basis for claim and suit based on negligence. One key indicator for the need for an emergency action plan is the concept of foreseeability. The organization administrators and the members of the sports medicine team must question whether a particular emergency situation has a reasonable possibility of occurring during the sport activity in question. For example, if it is reasonably possible that a catastrophic event such as a head injury, spine injury, or other severe trauma may occur during practice, conditioning, or competition in a sport, a previously prepared emergency plan must be in place. The medical and allied health care personnel must constantly be on guard for potential injuries, and although the occurrence of limb-threatening or life-threatening emergencies is not common, the potential exists. Therefore, prepared emergency responders must have planned in advance for the action to be taken in the event of such an emergency. - In Gathers v Loyola Marymount University, the state court settlement included a statement that care was delayed for the injured athlete, and the plaintiffs further alleged that the defendants acted negligently and carelessly in not providing appropriate emergency response. These observations strongly support the need to have clear emergency plans in place, rehearsed, and carried out. In several additional cases, the courts have stated that proper care was delayed, and it can be reasoned that these delays could have been avoided with the application of a well-prepared emergency plan. - Perhaps the most significant case bearing on the need for emergency planning is Kleinknecht v Gettysburg College, which came before the appellate court in 1993. In a portion of the decision, the court stated that the college owed a duty to the athletes who are recruited to be athletes at the institution. Further, as a part of that duty, the college must provide ''prompt and adequate emergency services while engaged in the school-sponsored intercollegiate athletic activity for which the athlete had been recruited.'' The same court further ruled that reasonable measures must be ensured and in place to provide prompt treatment of emergency situations. One can conclude from these rulings that planning is critical to ensure prompt and proper emergency medical care, further validating the need for an emergency plan.

Need for emergency plans :

Emergencies, accidents, and natural disasters are rarely predictable; however, when they do occur, rapid, controlled response will likely make the difference between an effective and an ineffective emergency response. Response can be hindered by the chaotic actions and increased emotions of those who make attempts to help persons who are injured or in danger. One method of control for these unpredictable events is an emergency plan that, if well designed and rehearsed, can provide responders with an organized approach to their reac- tion. The development of the emergency plan takes care and time to ensure that all necessary contingencies have been in- cluded. Lessons learned from major emergencies are also im- portant to consider when developing or revising an emergency plan. Emergency plans are applicable to agencies of the govern- ment, such as law enforcement, fire and rescue, and federal emergency management teams. Furthermore, the use of emergency plans is directly applicable to sport and fitness activities due to the inherent possibility of ''an untoward event'' that requires access to emergency medical services. Of course, when developing an emergency plan for athletics, there is one notable difference from those used by local, state, and federal emergency management personnel. With few exceptions, typically only one athlete, fan, or sideline participant is at risk at one time due to bleeding, internal injury, cardiac arrest, shock, or traumatic head or spine injury. However, emergency planning in athletics should account for an untoward event involv- ing a game official, fan, or sideline participant as well as the participating athlete. Although triage in athletic emergency situations may be rare, this does not minimize the risks involved and the need for carefully prepared emergency care plans. The need for emergency plans in athletics can be divided into 2 major categories: - professional and legal.

Personnel :

In an athletic environment, the first person who responds to an emergency situation may vary widely; it may be a coach or a game official, a certified athletic trainer, an emergency medical technician, or a physician. This variation in the first responder makes it imperative that an emergency plan be in place and rehearsed. With a plan in place and rehearsed, these differently trained individuals will be able to work together as an effective team when responding to emergency situations. The plan should also outline who is responsible for sum- moning help and clearing the uninjured from the area. In addition, all personnel associated with practices, com- petitions, skills instruction, and strength and conditioning activities should have training in automatic external defibrillation and current certification in cardiopulmonary resuscitation, first aid, and the prevention of disease transmission.

Venue location :

The emergency plan should be venue spe- cific, based on the site of the practice or competition and the activity involved (Table). The plan for each venue should encompass accessibility to emergency personnel, communication system, equipment, and transportation. At home sites, the host medical providers should orient the visiting medical personnel regarding the site, emergency personnel, equipment available, and procedures associated with the emergency plan. At away or neutral sites, the coach or athletic trainer should identify, before the event, the availability of communication with emergency medical services and should verify service and reception, particularly in rural areas. In addition, the name and location of the nearest emergency care facility and the availability of an ambulance at the event site should be ascertained.

Transportation :

The emergency plan should encompass transportation of the sick and injured. Emphasis should be placed on having an ambulance on site at high-risk events. Emergency medical services response time should also be factored in when determining on-site ambulance coverage. Consideration should be given to the level of transportation service that is available (eg, basic life support, advanced life support) and the equipment and training level of the personnel who staff the ambulance. In the event that an ambulance is on site, a location should be designated with rapid access to the site and a cleared route for entering and exiting the venue. In the emergency eval- uation, the primary survey assists the emergency care provider in identifying emergencies that require critical intervention and in determining transport decisions. In an emergency situation, the athlete should be transported by ambulance to the most appropriate receiving facility, where the necessary staff and equipment can deliver appropriate care. In addition, a plan must be available to ensure that the activity areas are supervised if the emergency care provider leaves the site to transport the athlete.

Emergency Care Facilities :

The emergency plan should incorporate access to an emergency medical facility. In selec- tion of the appropriate facility, consideration should be given to the location with respect to the athletic venue. Consideration should also include the level of service available at the emer- gency facility. The designated emergency facility and emergency medical services should be notified in advance of athletic events. Furthermore, it is recommended that the emergency plan be reviewed with both medical facility administrators and in-service medical staff regarding pertinent issues involved in athlete care, such as proper removal of athletic equipment in the facility when appropriate.

Professional need :

The first category for consideration in determining the need for emergency plans in athletics is organizational and professional responsibility. Certain governing bodies associated with athletic competition have stated that institutions and organizations must provide for access to emergency medical services if an emergency should occur during any aspect of athletic activity, including in-season and off- season activities. The National Collegiate Athletic Associa- tion (NCAA) has recommended that all member institutions develop an emergency plan for their athletic programs. The National Federation of State High School Associations has recommended the same at the secondary school level. The NCAA states, ''Each scheduled practice or contest of an institution-sponsored intercollegiate athletics event, as well as out-of-season practices and skills sessions, should include an emergency plan.'' The 1999-2000 NCAA Sports Medicine Handbook further outlines the key components of the emergency plan. Although the 1999-2000 NCAA Sports Medicine Handbook is a useful guide, a recent survey of NCAA member institu- tions revealed that at least 10% of the institutions do not maintain any form of an emergency plan. In addition, more than one third of the institutions do not maintain emergency plans for the off-season strength and conditioning activities of the sports. Personnel coverage at NCAA institutions was also found to be an issue. Nearly all schools provided personnel qualified to administer emergency care for high-risk contact sports, but fewer than two thirds of institutions provided adequate per- sonnel to sports such as cross-country and track. In a memorandum dated March 25, 1999, and sent to key personnel at all schools, the president of the NCAA reiterated the recom- mendations in the 1999-2000 NCAA Sports Medicine Hand- book to maintain emergency plans for all sport activities, in- cluding skill instruction, conditioning, and the nontraditional practice seasons. A need for emergency preparedness is further recognized by several national organizations concerned with the delivery of health care services to fitness and sport participants, in- cluding the NATA Education Council, NATA Board of Certification, Inc, American College of Sports Medicine, Inter- national Health Racquet and Sports Club Association, American College of Cardiology, and Young Men's Christian Association. The NATA-approved athletic training educational competencies for athletic trainers include several references to emergency action plans. The knowledge of the key components of an emergency plan, the ability to recognize and appraise emergency plans, and the ability to develop emergency plans are all considered required tasks of the athletic trainer.11 These responsibilities justify the need for the athletic trainer to be involved in the development and application of emergency plans as a partial fulfillment of his or her professional obligations. In addition to the equipment and personnel involved in emergency response, the emergency plan must include consideration for the sport activity and rules of competition, the weather conditions, and the level of competition. The variation in these factors makes venue-specific planning necessary because of the numerous contingencies that may occur. For example, many youth sport activities include both new participants of various sizes who may not know the rules of the activity and those who have participated for years. Also, outdoor sport activities include the possibility of lightning strikes, excessive heat and humidity, and excessive cold, among other environmental concerns that may not be factors during indoor activities. Organizations in areas of the country in which snow may accumulate must consider provisions for ensuring that accessibility by emergency vehicles is not hampered. In addition, the availability of safety equipment that is necessary for participation may be an issue for those in underserved areas. The burden of considering all the possible contingencies in light of the various situations must rest on the professionals, who are best trained to recognize the need for emergency plans and who can develop and implement the venue-specific plans.