Medical Director Message August 2022

Dominic Silvestro, Paramedic

EAP - August 1, 2022

Dominic Silvestro is an EMS Educator and EMS coordinator for the UH EMS Institute

As we head into the fall, high school, college, and pro sports seasons, The University Hospitals EMS Training and Disaster Preparedness Institute wanted to revisit the sports injuries / FRST education program as our focus for August Education.

FRST stands for First Responder Sports Trauma TM. FRST was developed by Dr. Robert Flannery MD of the University Hospitals Sports Medicine Institute. Dr. Flannery serves as Assistant Medical Physician for the Cleveland Browns, Team Physician for Oberlin College, St. Ignatius High School, and the Musculoskeletal Ultrasound Director.

Throughout August, I will be highlighting some of the key points of the FRST course, and Dr. Flannery’s lecture will be covered in your monthly CE. Our goal is to ensure that our athletes receive the best care possible and that our EMS and school medical staff are on the same page when that care is needed on the field.

The goal of the FRST program is to identify four situations that are unique to sports and athletic events where a knowledge gap has been found and designed to start a dialogue between the on-field athletic medicine team and the EMTs, paramedics, and firefighters who will be transporting the athlete to the hospital. It is extremely important that your EMS service establishes a relationship with the people who will be the on-field athletic trainers and physicians. You should learn their treatments, capabilities, and procedures for an injured athlete. You should share with them your level of service providers, protocols, and equipment you provide in the event of an emergency. Most importantly, you should work together as a team to have a solid Emergency Action Plan tailored to your facilities. 

Prior to each game, the attending EMS crew and sports medicine staff should hold a huddle of their own to discuss that particular game, the EAP, and on-field hand signals the medical staff will use to alert the EMS crew to come on to the field, as well as what equipment may be needed. 

There are many formats for creating an Emergency Action Plan or EAP. Your department may already have one that you use for other events in your area. The trainers also have access to a standard EAP on the UH drive that Dr. Flannery has posted for them. The plan should include: 

Whatever your EMS service and the school medical staff feel are important to include should be added to your EAP. Every EAP should be practiced and changed annually at a minimum. Dr. Flannery discussed one incident at a school about after hitting the game-winning shot, a student-athlete went into cardiac arrest. The EAP was activated. Someone immediately ran to the location of the AED in the Principal’s office which ended up being locked. After many minutes, the key was located, the AED was brought to the athlete’s side, and the battery was dead. The plan was good, but the lack of practice and logistical checks led to a poor outcome. 

On the reverse side, he discussed a story of a high school in Birmingham, Alabama. Some students were moving a portable goal post and hit some power lines, and all three students were taken down. The student trainers knew the EAP, activated it, and used the AED.  All three students walked out of the hospital. 

The FRST Program uses the P.R.E. G.A.M.E acronym to better assess everyone in how to plan for and carry out their EAPs:  

Over the next 4 weeks, we will discuss the medical conditions and sports Injuries that are part of the FRST program. These are all based on the fact that 90% of all athlete deaths occur from one of 4 major categories: heat, heart, head, and hydration. 

Respectfully Yours,

Dominic Silvestro EMT-P, EMS-I

University Hospitals EMS Training and Disaster Preparedness Institute     

Athletic Trainers - August  8, 2022

Last week I discussed how important it is to establish a good working relationship with your local school’s athletic trainers, sports physicians, and staff, as well as the importance of a solid Emergency Action Plan (EAP) for each venue. Ultimately, our goal is to ensure that our athletes receive the best care possible when injured or experiencing a medical emergency. 

There are four major medical conditions/sports injury categories that lead to 90% of all athlete deaths. They are Heart, Heat, Head, and Hydration. 

First up, the heart’s role in these athlete deaths and what EMS and the school’s athletic training staff can do together to provide the best possible chance of survival. 

In most cases, there is no warning or sign of struggle prior to SCA in athletes. Death may be the presenting symptom. Autopsies of these athletes have shown coronary artery anomalies, hypertrophic cardiomyopathy, and intermediate left ventricular hypertrophy as causes of some of these deaths. However, more and more autopsies show structurally normal hearts, and the cause of death is arrhythmia. These arrhythmias might not be found on a pre-participation exam or EKG. Studies have also shown that there does not appear to be a particular time in a game or length of training associated with these SCA events in athletes.

AED knowledge helps:

Commotio Cordis, while not common, does account for about 20% of all sudden cardiac arrests in athletes. It is caused by a blunt, non-penetrating blow to the chest. In Commotio Cordis, the blunt force hit to the chest occurs on the upslope of the T Wave, causing the patient to go into a ventricular arrhythmia usually ventricular fibrillation. This condition is often missed because the athlete may remain ambulatory for several seconds after the impact before the collapse. There may also be what appears to be seizure-like activity further masking the condition and delaying proper recognition of cardiac arrest. These are usually athletes with structurally normal hearts. Early CPR and defibrillation are the keys to a perfectly normal recovery. 

In next week’s Monday Morning Message, we will discuss the role of heat illness in our athletes, the use of immersion in cold water, and how our EMS response may be altered in these situations. Many thanks to Dr. Robert Flannery of the University Hospitals Division of Sports Medicine, Department of Orthopedic Surgery, for his FRST Course, guidance, and expertise. Dr. Flannery is committed to ensuring that student athletes get the best possible care available and that trainers and EMS personnel have the protocols, education, and tools to provide evidence-based lifesaving care when responding to critically ill or injured athletes.       

Respectfully Yours,

Dominic Silvestro EMT-P, EMS-I

University Hospitals EMS Training and Disaster Preparedness Institute     

Heat Emergencies - August 15, 2022

This week I would like to discuss how heat and humidity affect athletes. We will also discuss a new treatment for EMS and the changes to the hyperthermia/heat exposure protocol that address this change in patient care.

A heat illness can be defined as a serious medical condition resulting from the body’s inability to cope with a particular heat load. The body loses its heat balance because it cannot shed heat at a fast enough rate. The most effective way for the body to shed heat is by evaporation through sweating and the respiratory tract. When humidity levels are >75%, evaporation becomes ineffective for heat transfer.

The University Hospitals prehospital care protocol and treatment guidelines define the following 3 conditions in the hyperthermia/heat exposure protocol:

Treating Heat Stroke – A New Concept (Delayed Transport)

In basic EMT school, and in past protocol guidelines, we were taught that the best way to cool a heat exposure/heat stroke victim was by placing ice packs on the groin, neck, and axilla. While this is still the accepted treatment, ice water immersion (when available) is the preferred treatment for the patient with heat stroke.

Ice water immersion involves placing the heat stroke patient in a tub of ice and water up to their neck until their core temperature reaches 102⁰F. Professional, college, and now many high school sports medical staff have these tubs. They will be ready to go at all practices and games where heat and humidity are issues. EMS should work with their local schools and discuss the use of these tubs in their Emergency Action Plans. 

Why Ice Water Immersion

The chart below shows the effect of ice water immersion on reducing core body temperature. Ice water immersion will decrease core body temperature by 0.3⁰ C or 0.5⁰F per minute, as seen on the far right side of the chart. Looking to the far left of the chart, we see the effects, or lack thereof, in using ice packs or wet towels to attempt to cool these patients. 

Even in the Emergency Department, where cooling attempts will be done using a tarp or body bag filled with ice and water, a temperature reduction of 0.2.5⁰F per minute is all that can be achieved. The new Hyperthermia/Heat Exposure Protocol has a column that addresses the use of immersion and what to do if you arrive on the scene and the patient is in the tub or the tub is available and can be set up and ready to go in 5 minutes.

Ultimately, immersion in the tub is the best treatment for our heat stroke patient. Every effort should be made to keep the patient in the tub until the core temperature reaches 102⁰F. In many cases, the athlete is already being placed in the tub as EMS is being called. Once on scene, given the fact that core temp decreases by 0.5⁰F per minute, the delay in transport will be minimal. Not using the tub or pulling the athlete from the tub too soon can be deadly. 

Ice packs or even hospital treatment for heat stroke are not as good as ice water immersion. We would use an AED on a cardiac arrest patient if it was available because it is the best treatment for that condition. Ice water immersion is clearly the best treatment for heat stroke patients and should be used when available, even if it means a slight delay in your on-scene time. 

Thank you again to Dr. Robert Flannery of the University Hospitals Division of Sports Medicine, Department of Orthopedic Surgery for his FRST Course, as well as his guidance in protocol development and for ensuring that EMS understands the conditions that affect our athletes and how to best treat them when they occur. 

Respectfully Yours,

Dominic Silvestro EMT-P, EMS-I

University Hospitals EMS Training and Disaster Preparedness Institute 

Concussion - August 22, 2022

Continuing our month-long discussion on the illnesses and injuries that affect our athletes, this week’s focus is head injuries since they occur in all sports. Over the last several years, there has been an emphasis on head injury prevention, identification, and treatment. You hear terms like the concussion protocol, go or no go, traumatic brain injury (TBI), etc. Head injury can occur in any sport. It is important to know the signs and symptoms of traumatic brain injury, remove that player from the game, and, if necessary, transport them to the hospital for further evaluation. 

While it is not necessarily the concussion that is a life-threatening emergency, it is when the injury stops being a concussion and turns into a subdural or epidural hematoma, and now is a threat to life. Knowing what is common in a concussion, and what you should expect to see, will help you identify the more serious conditions. 

Per the CDC, a concussion is a brain injury (TBI) caused by a bump, blow, jolt to the head, or by a hit to the body, that causes the head and brain to move rapidly back and forth. This sudden movement can cause the brain to bounce around or twist the skull, creating chemical changes in the brain, sometimes stretching and damaging brain cells. Because concussions are not usually life-threatening, they may be described as “mild” brain injuries. However, the effects of a concussion can sometimes be serious and, if not ignored, have lasting effects.

Concussion signs can include:

Common symptoms of a concussion include: 

Signs and symptoms generally appear soon after the injury but may present a few hours later. Ohio Law requires that any athlete with a “suspected” concussion must be held out for 24 hours and cleared by a medical professional before playing again. Athletic trainers, team physicians, or in some cases, on-scene EMS, should evaluate the athlete and make the “go or no go” determination for return to play.

Along with the mechanism of injury, the athlete’s ability to return to play will be determined by a physical exam, and whether the athlete can answer questions to help determine if they are alert and oriented to a person, place, time, and event. When pulled from play, the athlete should be constantly monitored and reevaluated for signs of a more serious head injury. Look for changes in mental status, vomiting, progression of headache, one dilated pupil, or any other decline in the patient’s condition. If this occurs, the athlete must be immediately transported to the hospital for further evaluation.  

A Word on Helmets

Helmets are being worn in many sports, even where they might not have been used a decade ago. The old leather football helmet of the 1920s did not do a whole lot to protect the football player from injury, and as a result, many players died from skull fractures. So, they began making helmets out of plastic. These helmets did a much better job protecting the players from a skull fracture. Over the decades, the plastics, padding, and design improvements lessened the number of football players dying from skull fractures. Players began leading with and using their helmets as a weapon in blocking and tackling. This led in the ’70s – ‘80s to rules banning spearing or any leading with the head to protect the neck. Notice in this little history lesson that the thought of protecting players from concussion was never mentioned. That’s because the first helmet designed to protect against concussion and skull fracture did not come out until 2018. 

When meeting to discuss their Emergency Action Plans, ask your local school’s athletic trainers and staff what generation of football helmets their players are wearing, if the school switched to concussion-resistant helmets, or are they in the process of switching over, and if so, how many players have the newer helmets? You should also ask the staff what protocols they are using to evaluate whether a player can return to play. 

Take time to review your transport area and determine which hospitals in your area are equipped to handle traumatic brain injury in both adult and pediatric patients, so you are prepared to transport these patients to the most appropriate hospital in the event of a head injury.

Respectfully Yours,

Dominic Silvestro EMT-P, EMS-I

University Hospitals EMS Training and Disaster Preparedness Institute  

Spinal Cord Injuries - August 29, 2022

This week I will be wrapping up our 5-week discussion on the content found in the FRST (First Response for Sport Trauma) with a brief review of spinal injuries in athletes, as well as the Pre-Game Time Out that should occur at our sporting events. 

Millimeters Matter 

Anatomically, the width of the cervical spinal column is between 17--18mm in, and the diameter of the spinal cord is between 9 -14mm. In an athlete with a suspected spinal injury, C-Spine stabilization is critical because millimeters matter.

50% of Spinal cord injuries are Complete Cord injuries. In sports, these are usually not the result of the cord being cut, rather bruising or lack of blood supply. The other 50% of spinal cord injuries are incomplete spinal cord injuries. These athletes will still have some function below the lesion. However, if these injuries are not handled correctly, they can deteriorate to complete spinal cord injuries. Every effort should be made to maintain inline stabilization throughout treatment and transport of the athlete. 

Spinal Stabilization 

Athletes without helmets and shoulder pads, who have a suspected spinal injury, are immobilized the same way you would immobilize any other patient with a suspected spinal injury. Treatment changes slightly when an athlete is wearing a helmet and shoulder pads, as we see in football, hockey, and lacrosse. Ideally every effort should be made to leave the helmet and shoulder pads on, and we should only remove the facemask. When properly worn the helmet and shoulder pads together keep the spine in proper alignment (left photo). Removing one or the other alone (center and right photo) results in improper alignment.  

If the shoulder pads or helmet need to be removed, do not pull or tug on the jersey, or any straps, ties, buckles, or snaps. Cut these using standard medic scissors and allow the equipment to fall to the side or open. Use a tilt lift, from the waist of the patient, while a rescuer maintains c-spine stabilization from the front of the patient, helmet, and shoulder pad removal can then be accomplished. The patient would then be lowered to the ground, and c-spine stabilization is handed back to the rescuer at the head of the patient. Placing the athlete on a backboard can be done using either a log roll or a multiple rescuer lift. The use of a backboard is preferred in larger athletes. The standard EMS Vacuum Mattress will tend to bend when lifting larger athletes and not provide the same rigidity. It is also important to note that The National EMS Spine Injury Standards, as reflected in our EMS Spinal Motion Restriction Protocol, can be used by athletic trainers and team physicians to indicate whether an athlete requires immobilization or not. As always, error on the side of caution and immobilize if you feel it is necessary. 

Pre-Game Time Out 

We discussed the importance of working with your local school's medical staff to help create and practice their Emergency Action Plans (EAP) for each sport venue on their campus. Dr. Flannery is working at the State level to establish requirements for a Pre-Game Time Out for everyone who may be involved in the care of an injured athlete, or in the activation and execution of the EAP. This would be a pre-game huddle with the trainer and team physicians of both teams, EMS, game officials, school maintenance staff, etc. During this brief meeting, the parties involved should review the EAP, not the medical expertise available on scene, as well as location of AEDS, supplies, tools for mask removal, and hand signals or communication needed, ambulance location and access, and any other job assignments in the event of an emergency. 

It is our hope that your service will take the time to visit and meet with the medical staff at your local schools, colleges, and universities to discuss their EAP’s, practice them, and become partners in the care of their athletes. Thank you again to Dr. Robert Flannery of the UH Division of Sports Medicine for his work in developing the FRST program, for his passion in reducing injury and death in our athletes, as well as making sure that all parties involved in the care of these athletes are well trained and working together for positive outcomes. 

Respectfully Yours,

Dominic Silvestro EMT-P, EMS-I

University Hospitals EMS Training and Disaster Preparedness Institute