Sports pre-hospital immediate care courses in the United Kingdom - attempting to “treat” sudden cardiac death.

Dr Jonathan Richard Hanson
Department of Sport and Exercise medicine.
Musgrave Park Hospital
Belfast

Tel. +441471844478 / +447795166039
jonathanhanson@btinternet.com
Keywords. Sports, pre-hospital, cardiac, trauma, course

 

Abstract

A description of the current state of sports pre-hospital immediate care training for pitchside doctors and physiotherapists in the United Kingdom. The background and development of such courses is covered, as are the major skills and revalidation procedures. Course credibility through professional regulation and instructor selection is discussed, as are the differences between the sports pre-hospital courses and traditional in-hospital resuscitation and trauma courses. Official policy from the Faculty of Sports and Exercise Medicine in the UK is considered and recommendations for change suggested.

 

Introduction

Athletic sudden cardiac death pre-participation screening remains controversial(1,2). The range of responsible pathology reflects both genetic (cardiomyopathy or ion channelopathies) and acquired (ischaemic heart disease or post viral cardiomyopathies) causes (2). Despite the host of methods used as possible screening tools (family history, clinical examination, resting or exercise ECG, echocardiography and even MRI) some cases will always slip through the net (2). The team physician or, more commonly, the physiotherapist will then be first responder to a collapsed arrested athlete.

When this screening is extrapolated to the wider population for whom medics are not present during athletic activity, the picture is even more complicated and Advisory External Defibrillator (AED) availability and layperson first responder training will play a role in increasing survival (3).

The injury patterns of various sports and potential for trauma can also mean the same individuals may be required to deal with the initial stabilisation of potentially serious trauma.

Some sports such as motorsport have the potential for high energy trauma and as such have medical provision involving paramedics and emergency medicine specialists. For the majority of team sports responsibility may sit with the team physiotherapist.

Sports physicians are not trauma or critical illness specialists. Most have a general practice background. The initial medical care that a critically injured or arrested athlete will receive is most likely from individuals who do not deal with critical care situations on a regular basis.

What follows is a description of the need for sports immediate care courses for doctors and physiotherapists in the UK, the existing courses and a discussion about their development.

 

Immediate care in the sporting environment - matchday versus training situations

In terms of immediate care provisions, “matchday” can be very different from the training setting. Matchday situations may have ambulance and paramedic cover and even medical staff with relevant critical care specialties in the crowd. However the obvious void in their training is familiarity for entering the field of play and co-ordinating teams of unfamiliar healthcare professionals. Depending on the clinical situation, this has various levels of relevance. For example a cardiac arrest would undoubtedly end play for the day, an unconscious face down rugby player would not. Safe assessment, extrication and transfer is crucial in ensuring that no further harm comes to the athlete, yet as appropriate, the sporting activity can continue. The outcome of this whole process may be influenced through immediate care planning that has taken place prior to the event (4). Such planning covers areas such as signals, designated roles, equipment checking drills and selection and provisions of the medical room at the ground.

From a training perspective, immediate care planning for protocols/roles and equipment storage are advantageous when considering potential critical incidents in environments such as the weights room or remote green field sites(4).

Sports coaching and training methods have also fundamentally changed over the past ten years. Warm ups are more dynamic and the general focus of modern coaching is on sports specific events to influence the athletes ability to react under pressure. Thus in many sports training situations mirror matchplay. In rugby the days of unopposed training are generally behind us and full contact drills are seen more often. In field hockey, drills defending the penalty corner are commonplace. The athletes are stronger and hit the ball harder. An athlete can spend around three times as long training as he does competing each week so potential immediate care incidents in training should not be overlooked.

Improving the immediate care skills of the pitchside medic.

The drive to improve the skill base for the pitchside medic has come from various sources. Sports physicians with a background of emergency medicine and paramedical services recognised the challenges (Gillett M. REMO Sports Ltd personal communication), as did the pitchside medics themselves who began actively seeking additional relevant training (LM Medical. personal communication). Individual sports recognised the athlete welfare and pitchside challenges for its medical staff and have either developed their own courses and/ or changed legislation to improve the minimum standard of care an athlete should receive (5). For example the GB Hockey Union fundamentally changed its policy for immediate care equipment and training following a major airway injury to an elite athlete in competition.

Prior to the development of sports specific courses some sports physicians looked to the Advanced Life Support, Advanced Trauma Life Support course or the British Association of Immediate Care (BASICS). The National sports medicine institute also ran a course for anyone interested in sport from parents, referees to healthcare workers. This has recently been updated.

Core syllabus

-Skills The skills generally covered include basic airway management, airway adjuncts up to laryngeal mask insertion, needle cricothyroidotomy, management of the unconscious casualty, management of potential cervical spinal injury on the field of play, oxygen therapy, recognition of life threatening injuries such as chest injuries or occult abdominal bleeding, basic life support, the advisory external defibrillator (AED), logrolling, scoop and spine board extrication and management of open and closed long bone fractures. Other areas may include anaphylaxis, choking or medical emergencies.

-Planning Immediate care planning prior to the event, working in small teams, promoting CPD, drawing up policy, protocols and guidelines.

-Leadership and teamwork – Favourable outcomes in stressful situations need strong leaders and efficient team working. Some courses highlight this area as a crucial skill.

-Minimum standards of kit Coverage for training and matchday situations are generally explained and some courses even provide an avenue to purchase appropriate kit (REMO).

The differences between the injury patterns and player anthropometrics of different sports justify the tailoring of courses to individual sports.

As a practical outdoor speciality, the majority of the courses concentrate on practical small group teaching.


Exisiting Trauma and Resuscitation courses and the Pitchside Medic.

The Resuscitation Councils Advanced Life Support (ALS), although an excellent course for those dealing with complicated arrest situations on a regular basis, teaches many skills such as rhythm recognition and cardiac arrest drugs (6), that are not needed by the pitchside medic. Pre-hospital cardiac arrest situations can be effectively managed in terms of improved discharge from hospital by automated external defibrillators and effective basic life support (3) ATLS is an in-hospital course for situations where many pairs of skilled hands and equipment are readily available (7). BASICS is a prehospital course targeted at those who do not deal with critical injury every day such as the rural general practitioner. Many aspects of BASICS are transferable to pitchside work but some time is spent dealing with cover higher energy trauma from motor vehicle accidents. None of the courses train practitioners to think and plan for critical care scenarios in a sports setting. Nor do they provide the candidate with potentially single-handed management under the pressure of a sports setting. Other pre-hospital areas such as mountain rescue teaching has something to offer sports pre-hospital critical care in terms of equipment, potentially isolated setting, safe extrication and transfer. (8).

The tried and tested teaching framework for resuscitation skills and adult learning utilised by the mainstream in hospital courses has been applied to most of the currently available sports courses.

Although many skills from the existing mainstream avenues are transferable, such courses have now been superceded by more appropriate options.

Currently the advice of the Faculty of Sports and Exercise Medicine of the Royal College of Surgeons of Edinburgh still states that sports physicians should be trained to ALS and ATLS standards (Faculty. Personal Communication December 2008). It is time for this position to be re-considered in favour of more suitable sports pre-hospital immediate care courses.


Which courses are available?

We are fortunate to now be in a position where the available courses have such geographical spread that any doctor or physiotherapist working in sport in the UK should have easy access to a sports specific pre-hospital critical care course. Most of these courses are recognised by a higher professional body (usually the pre-hospital care faculty of then Royal College of Surgeons of Edinburgh or the Royal College of Surgeons of Ireland). The advantages of recognition are openness and credibility through higher professional regulation. Most courses have some degree of mutual recognition, although readers are urged to clarify the current position when undertaking any course.

Different courses predominate by region and by sport. One of the underlying themes in them all is pre-event planning. Thus members of the medical teams are encouraged to talk through the differences and plan for the “what ifs?” prior to an event. Subtle differences in teaching should in theory be ironed out through planning when candidates work together in a sport.

There are however differences in the manner in which the skills are taught and in the regulatory bodies with which the courses are professionally affiliated. There is also a significant range in cost between the courses (range of £200 to £575). Most courses run over two to three days and incorporate MCQ, lectures, skill stations, small group discussions and scenario teaching.

Currently the following courses are specifically training healthcare professionals to manage sports specific pre-hospital critical care scenarios.

Table 1. Major Sports pre-hospital Care courses in UK 2008 (In alphabetical order)

AREA (Advanced resuscitation and emergency aid.)
Run by REMO sports Ltd. This course is specific and mandatory for the doctors and physiotherapists involved with the Premier League level of association football. The Area course is currently the only UK course to be accredited by the Pre-hospital care faculty of the Royal College of surgeons of Edinburgh. (Nb) SCRUMCAPS, IMMOFP and the RFU pre-hospital care course are all approved by the same professional body

IMMOFP – Immediate medical management on the field of play
This course is provided by the Rugby Football League based in Leeds in the north of England. It is a mandatory requirement for all medical staff in professional or age group representative rugby league

REMO Sports Ltd. -Resuscitation and Emergency management on the field of play.
This is one of the first courses to appear and provides generic skills to cover a host of sports from contact field sports through to mountain biking. With progression they have also expanded the variations on the theme to include scenarios such as water based rescues for diving injuries and more focused courses for target areas of health care professionals (eg) EIS or REMO “Cricket”. Based in the Midlands of England but offer courses remotely. REMO staff also provide mini-courses as part of other organisations (such as the British institute of musculoskeletal medicine course).

LM Medical. -Sports Trauma course.
Wales/ West of England and further afield. A paramedic led course that has trained over 1500 people in sports pre-hospital critical care.

PSITCC- Pre-hospital trauma care course. Rugby Football Union
PSITCC- Pre-hospital sports injury trauma care course. Rugby Football Union, London. Mandatory course for professional and age group representative English Rugby Union.

SCRUMCAPS – Scottish Rugby Union Medical Cardiac and Pitchside skills.

Edinburgh, Scotland. Predominantly Rugby Union course aimed at professional, representative and amateur levels. Also available to all sports however.

SPORTPROMOTE- Scottish Football Association course Hampden Park, Glasgow. Aimed at professional football in Scotland

 

Instructors.

There are fundamental differences in the background of the instructors between courses. Most, but not all, draw on the experience of using instructors who have undergone generic instructor training under another guise – usually the mainstream courses of Advanced Life Support, Advanced trauma life support, European Paediatric life support or BASICS. The focus is on the fact that the instructors are trained in small group teaching, practical skill station teaching, mentoring and giving feedback via a generic instructor course (GIC).

Some courses operate by only having relevant specialists teaching their specialist areas, some show more crossover and some do not regulate who teaches what.
Some courses select instructors purely on performance as providers on the course and do not require they go through an additional course covering how to train adult learners in resuscitation skills.

Availability of instructors can sometimes be under pressure, principally due to the recent changes in medical training in the United Kingdom through Modernising medical careers and the ruling that all foundation level junior doctors must complete an Advanced Life Support course (9). Thus the goodwill for release of instructors by health trusts can sometimes be stretched with yet “another” course.

Revalidation
Most courses follow a cycle of certification as competent that lasts two to three years. Some courses offer “updates” or “one day refreshers”. These are to be encouraged.

Regulatory bodies.
Most courses are associated with either the Pre-hospital care faculty of the Royal College of Surgeons of Edinburgh (RCSEd) or the Faculty of Sports and Exercise Medicine of the Royal College of Surgeons of Ireland. Some courses have also achieved formal recommendation by the Association of Chartered Physiotherapists in Sports Medicine (ACPSM).

This association provides recognition and quality assurance in terms of the standards and assessment of skills taught and the relationship is to be encouraged. It also allows a number of the courses to mutually recognise each other under a common umbrella. This is useful in terms of revalidation and avoids repetition of the same skills when practitioners branch out into other regions or other sports.

Physiotherapy recognition through the ACPSM is crucial, both in terms of continuing professional development, but also in terms of giving a degree of shared ownership of the course, rather than being “doctor heavy” and both potentially biased and intimidating.

Sports governing bodies.
Most sports governing bodies and medical committees recognise the importance of this area. The mandatory requirements of the RFL, RFU and Premier league for their own courses reflect this. However that is not to say other sports fail to recognise its importance.

Some sports such as field hockey have made great progress in the standards of emergency medical provisions in competition. This is partly due to a sentinel injury of a fractured larynx to the Great Britain captain caused by a blow to the neck in 2001 (Rossiter M. Chief Medical Officer England Hockey Union. Personal Communication).

Many readers will be familiar with the vascular injuries recently seen in professional ice hockey in Canada and the various onfield cardiac deaths in Association Football.

Policy is still decided on a national, rather than international level. In elite competition this is potentially an issue. Standardising pitchside critical care standards on an international level can only improve the quality of care all athletes receive.

Does it work?
No studies have looked at whether the informal network of courses in the UK has a measurable influence on improving the outcome of the athletes. However course evaluation forms suggest that the candidates feel more confident with planning for and managing pre-hospital sports critical care situations.

Summary.
Health care professionals in the United Kingdom have attempted to address the immediate management of pitchside critical care training for those who do not deal with critically unwell patients on a daily basis.

The result is a network of unconnected courses that show generally show mutual respect and recognition despite subtle differences in the regulation, delivery and syllabus of the various courses. The courses are suitably spread geographically across the country which enables suitable access to all healthcare professionals for continuing professional development.

Whether the expense of such courses improves outcome is unknown. We do however know that healthcare professionals feel better trained because of them. Cumulatively the courses have trained around two and a half thousand pitchside medics over the past eight years (REMO, LM Medical. Personal communication)

Long term challenges include the ongoing recruitment of adequately trained instructors and maintaining relationships between the courses for the benefit of the pitchside practitioner.

Pitchside practitioners looking to improve their skills in sports pre-hospital critical care are urged to examine the pros and cons of all available courses before deciding which one to follow.

 

Competing Interests declared
JH is a provider of the IMMOFP, REMO and ATLS courses and an instructor on the ALS, AREA, SPORTPROMOTE and SCRUMCAPS courses. He is also the author and course co-ordinator for SCRUMCAPS.

 

References

  1. Drezner JA, Khan K. Sudden cardiac death in young athletes. BMJ 2008; 337: a309.
  2. Papadakis M, Whyte G, Sharma S. Preparticipation screening for cardiovascular abnormalities in young competitive athletes. BMJ 2008; 337: a1596.
  3. PAD Trial Investigators. Public-access defibrillation and survival after out-of-hospital cardiac arrest. N Engl J Med 2004; 351: 637–646.
  4. Drezner JA, Courson RW, Roberts WO et al. Inter-association Task Force recommendations on emergency preparedness and management of sudden cardiac arrest in high school and college athletic programs: a consensus statement. J Athl Train 2007 Jan-Mar; 42(1):143-58.
  5. The Rugby Football League. IMMOFP Course Manual 2005.
  6. Resuscitation Council. Advanced Life Support manual. 5th Edition (revised) 2008.
  7. American College of Surgeons. Advanced Trauma Life Support Manual 8th Edition 2008.
  8. Hearns ST. First aid training and equipment in UK mountain rescue teams. Pre-hospital Immediate Care 1999; 3: 215-8.
  9. DEPARTMENT OF HEALTH (2005) Curriculum for the Foundation Years in Postgraduate Education and Training (draft). London: Department of Health.