Heat stroke treated on-scene?

[KellyBracket]

Does anyone have experience with being called for a likely heatstroke patient at an athletic event, but having the trainers refuse to have the patient transported until they have cooled the patient?

There are some position statements from the athletic trainers that seem to support this approach, but I haven't heard first-hand of any conflicts between EMS and trainers.

(See page 9 of this position statement from the NATA to read their reasoning)

 

[Uclabruin103]

Does anyone have experience with being called for a likely heatstroke patient at an athletic event, but having the trainers refuse to have the patient transported until they have cooled the patient?

There are some position statements from the athletic trainers that seem to support this approach, but I haven't heard first-hand of any conflicts between EMS and trainers.

(See page 9 of this position statement from the NATA to read their reasoning)

Our protocol is fluid and active cooling with rapid transport. I have no clue what the scope of practice of a trainer is unless their a doctor. With that I wouldn't let them take control of my patient's care if I was dispatched to a heat stroke call.

 

[Household6]

Page 9 whoa.. An athletic trainer is actually going to take an athlete's rectal temperature to assure it's not above 105?

Funny, I see a long list of contributing authors on that paper, but none of them have MD behind their name.

 

[Mariemt]

Once I'm called out, it is my patient. They can back off. Heat stroke is a true emergency and my fangs will come out

 

[Carlos Danger]

Does anyone have experience with being called for a likely heatstroke patient at an athletic event, but having the trainers refuse to have the patient transported until they have cooled the patient?

I have never personally been that situation, but I do recall doing a standby once and being instructed that the AT's are in charge and probably won't even call us over until they have done all of their assessments and treatments and are ready for the patient to be transported.

Funny, I see a long list of contributing authors on that paper, but none of them have MD behind their name.

MD's aren't the only people who can write. AT's are pretty well educated and are capable of writing recommendations.

Once I'm called out, it is my patient. They can back off. Heat stroke is a true emergency and my fangs will come out

The problem is, they won't call you out until they are "ready for you".

Athletic trainers are capable of handling most of what can go wrong on a sports field. Almost all of the one's I've known have been EMT's or EMT-I's.

 

[Mariemt]

I have never personally been that situation, but I do recall doing a standby once and being instructed that the AT's are in charge and probably won't even call us over until they have done all of their assessments and treatments and are ready for the patient to be transported.




MD's aren't the only people who can write. AT's are pretty well educated and are capable of writing recommendations.




The problem is, they won't call you out until they are "ready for you".

Athletic trainers are capable of handling most of what can go wrong on a sports field. Almost all of the one's I've known have been EMT's or EMT-I's.

the op said called out. Once I'm dispatched, the pt is mine.

 

[Rialaigh]

the op said called out. Once I'm dispatched, the pt is mine.

Once your dispatched you have the privilege of treating a patient that can refuse any and all aspects of your care...the patient can accept care from anyone else they deem fit to.

Getting territorial about patient care with people that (While not emergency providers) hold a higher level of education than you that includes a fair amount of medical and medicine related course work including specifically how to deal with athletic related injuries including heat stroke is just poor decision making.

 

[Sandog]

Page 9 whoa.. An athletic trainer is actually going to take an athlete's rectal temperature to assure it's not above 105?

Funny, I see a long list of contributing authors on that paper, but none of them have MD behind their name.

PhD. is a pretty respectable title and gives credibility.

 

[KellyBracket]

Page 9 whoa.. An athletic trainer is actually going to take an athlete's rectal temperature to assure it's not above 105?

There is actually a form available from the NATA that parents can sign beforehand, allowing the trainer to obtain a rectal temperature. However, at least one study suggests that, in reality, trainers check an oral temp far more often.

Anyways, there are a lot of hypothetical concerns with the NATA recommendation, I agree. I'm wondering how often these concerns have actually been borne out, though. I'm guessing these sorts of conflicts are pretty rare, but I thought I would check!

 

[Mariemt]

Once your dispatched you have the privilege of treating a patient that can refuse any and all aspects of your care...the patient can accept care from anyone else they deem fit to.

Getting territorial about patient care with people that (While not emergency providers) hold a higher level of education than you that includes a fair amount of medical and medicine related course work including specifically how to deal with athletic related injuries including heat stroke is just poor decision making.

The patient has the right to refuse treatment. The athletic director, ie: highschool, college etc does not have the right to tell me to wait etc.
If they are of higher medical training and working within their jurisdiction, that is a different story.
I have suffered heat stroke, the pt actually will not be able to refuse as they will most likely be altered anyway.

 

[Uclabruin103]

I tried to find a specific scope of practice for trainers, but was unable. Granted I didn't look too hard, but if it's a true emergency, then it's our realm. They seem to be more focused on prevention and treatment of sport injuries. If push came to shove and I ended up in court, I doubt my saying, "but the trainer said I should wait until the patient get cooled down." would save me.

Trainers should know when they're out of their realm. Just like I wouldn't even think of attempting to rehab a torn rotator cuff to a pitcher, they shouldn't delay our treating life-threatening medical emergencies. If we disagree, I'm sure my base hospital would set them straight.

 

[Akulahawk]

I tried to find a specific scope of practice for trainers, but was unable. Granted I didn't look too hard, but if it's a true emergency, then it's our realm. They seem to be more focused on prevention and treatment of sport injuries. If push came to shove and I ended up in court, I doubt my saying, "but the trainer said I should wait until the patient get cooled down." would save me.

Trainers should know when they're out of their realm. Just like I wouldn't even think of attempting to rehab a torn rotator cuff to a pitcher, they shouldn't delay our treating life-threatening medical emergencies. If we disagree, I'm sure my base hospital would set them straight.

Athletic Trainers have a very different scope of practice from what pretty much anyone is used to. They function under the medical license of their supervising physician and to a large degree, whatever the team physician is comfortable allowing the trainer to do that's in the trainer's education as a trainer is good to go.

The other thing with them is that they function within a closed medical system. Once they call EMS in, believe me, they know they're handing the athlete over to someone who is (overall) far less educated than they are, and that EMS takes over scene control once they arrive.

An ATC is a lot more capable of managing emergencies than you might think... they often simply lack the authorization. They'd probably pick up a lot of the psychomotor skills in very short order if they were authorized to use them.

If I'm working as a trainer, you'd better believe that I'm not calling EMS until I'm ready to release the athlete to EMS for transport to the ED because that's where that athlete needs to be.

 

[Akulahawk]

Does anyone have experience with being called for a likely heatstroke patient at an athletic event, but having the trainers refuse to have the patient transported until they have cooled the patient?

There are some position statements from the athletic trainers that seem to support this approach, but I haven't heard first-hand of any conflicts between EMS and trainers.

(See page 9 of this position statement from the NATA to read their reasoning)

For heat stroke patients, the ATC knows that immediate cooling is necessary and doesn't want to delay cooling measures any more than necessary. They'll institute cooling measures and call for EMS at an appropriate time so the athlete will be handed off to EMS very quickly and seamlessly. Actual conflicts between ATC's and EMS are pretty rare in my experience.

 

[Akulahawk]

Our protocol is fluid and active cooling with rapid transport. I have no clue what the scope of practice of a trainer is unless their a doctor. With that I wouldn't let them take control of my patient's care if I was dispatched to a heat stroke call.

That's a huge problem outside the sports med community. EMS doesn't know what an ATC is able to do, and doesn't recognize them as anything higher than a lay person.

 

[mycrofft]

The patient has the right to refuse treatment. The athletic director, ie: highschool, college etc does not have the right to tell me to wait etc.
If they are of higher medical training and working within their jurisdiction, that is a different story.
I have suffered heat stroke, the pt actually will not be able to refuse as they will most likely be altered anyway.

In a nutshell.
However, depends upon who can cool the victim down the fastest and best. Chem cold packs to axillae, groin, neck (and scalp,too!) cannot compare* to a wide-open garden hose with cool water, or an ice bath. (Yes, ice baths are finally being recognized, but as with any such measure you have to be careful!!). Prelim rapid cooling followed by air conditioned transport in damp sheets and/or ice packs may be the best. (Why fluids as a blanket measure?).


*As my long term cohorts here know, I consider chem cold packs to the groin etc a joke, a last ditch measure when you don't have real cooling facilities at hand. Better 'n nothing, but more in the nice try category.

 

[Akulahawk]

Comments inline, in red.

I have never personally been that situation, but I do recall doing a standby once and being instructed that the AT's are in charge and probably won't even call us over until they have done all of their assessments and treatments and are ready for the patient to be transported.
This is typical. They function in a closed medical system and as such, won't call you unless transport is needed or an advanced procedure is needed along with transport.



MD's aren't the only people who can write. AT's are pretty well educated and are capable of writing recommendations.
Yes, minimum entry level is a Bachelor's, and there is Master's and PhD programs too.



The problem is, they won't call you out until they are "ready for you".
Again, very typical. They know what they can handle, what they can't, and know that with very few exceptions, they're handing one of "their" athletes to someone with generally inferior education, who happens to be able to provide aspects of emergency care that they can not do themselves.

Athletic trainers are capable of handling most of what can go wrong on a sports field. Almost all of the one's I've known have been EMT's or EMT-I's.
Chances are pretty darned good that the Athletic Trainers probably had a reasonably easy time earning EMT or EMT-I.

 

[mycrofft]

Comments inline, in red.

THIS is a prime example of the dangers of sports standby. Who's on first, and who's in charge?

 

[Akulahawk]

In a nutshell.
However, depends upon who can cool the victim down the fastest and best. Chem cold packs to axillae, groin, neck (and scalp,too!) cannot compare* to a wide-open garden hose with cool water, or an ice bath. (Yes, ice baths are finally being recognized, but as with any such measure you have to be careful!!). Prelim rapid cooling followed by air conditioned transport in damp sheets and/or ice packs may be the best. (Why fluids as a blanket measure?).


*As my long term cohorts here know, I consider chem cold packs to the groin etc a joke, a last ditch measure when you don't have real cooling facilities at hand. Better 'n nothing, but more in the nice try category.

Ice bath, or even a cool water (< 59 deg. F) in a whirlpool is extremely effective. Wide open garden hose works well too. The problem with using damp sheets for cooling is that the body will warm up the water immediately next to it, thus limiting heat transfer. Same will happen with cool water baths if the water isn't agitated. Chem packs don't work that well... but are better than nothing.

 

[Akulahawk]

THIS is a prime example of the dangers of sports standby. Who's on first, and who's in charge?

Done correctly, that stuff will be addressed and will be well known and disseminated to all participants on the medical end of things. I've done sports standbys that were very well run and everyone knew where they fit in the overall plan... from physicians (team and stadium in that case), to the RN's working with the stadium physicians, to the ATC's on the field, to the Paramedics and EMTs in the venue. I know your last gig wasn't as well set up... by far. And that's all I'm going to say about that.

 

[Tigger]

Our protocol is fluid and active cooling with rapid transport. I have no clue what the scope of practice of a trainer is unless their a doctor. With that I wouldn't let them take control of my patient's care if I was dispatched to a heat stroke call.

So because you have no idea what the provider's background is, you must be in charge? Even though the provider in question has, at minimum, years more education than you and I?

Page 9 whoa.. An athletic trainer is actually going to take an athlete's rectal temperature to assure it's not above 105?

Funny, I see a long list of contributing authors on that paper, but none of them have MD behind their name.

I see plenty of RNs and Paramedics listed as contributing authors in studies and no one says a word about that. As mentioned, ATCs have at minimum a BS in Athletic Training, which is already far and above paramedic training and comparable in many ways to BSN (nearly identical perquisite education foundations). Not to mention that most contributing to research are going to be working for collegiate or professional organizations where a Master's is generally required.

Once I'm called out, it is my patient. They can back off. Heat stroke is a true emergency and my fangs will come out

the op said called out. Once I'm dispatched, the pt is mine.

The patient has the right to refuse treatment. The athletic director, ie: highschool, college etc does not have the right to tell me to wait etc.
If they are of higher medical training and working within their jurisdiction, that is a different story.
I have suffered heat stroke, the pt actually will not be able to refuse as they will most likely be altered anyway.

This is attitude is in a word, garbage. The patient is not "yours" once you are dispatched and to act as such is incredibly foolish. Lets face the facts, the ATC knows more about medicine than you (or I) do. To say that you are taking control of the patient in the face of this knowledge gap is again, foolish.

How do you determine altered anyway? Do you think your mental status exam is superior to that of the ATC? I'll give you a hint, it is not.

Saying that your "fangs will come out" is an indication of a considerable lack of professionalism. Odds are that if the higher trained medical provider called for an ambulance, he is well aware already that the patient requires transportation to the hospital. There is no need for attitude, but there is a need for cooperation.

I tried to find a specific scope of practice for trainers, but was unable. Granted I didn't look too hard, but if it's a true emergency, then it's our realm. They seem to be more focused on prevention and treatment of sport injuries. If push came to shove and I ended up in court, I doubt my saying, "but the trainer said I should wait until the patient get cooled down." would save me.

Trainers should know when they're out of their realm. Just like I wouldn't even think of attempting to rehab a torn rotator cuff to a pitcher, they shouldn't delay our treating life-threatening medical emergencies. If we disagree, I'm sure my base hospital would set them straight.

Athletic Trainers receive as much or more training than an EMT does in regards to life threatening injuries. There is nothing in the EMT scope of practice that an Athletic Trainer cannot do. If you think that they are going to stand there while one of their athletes deteriorates until EMS gets there to save the day, I'd have to bet you have never worked with one.

Also, it's not great form to make an argument based upon saying "I don't think this exists, but I didn't really look either." ATCs do not generally have a scope of practice as they do not work under a physician's license but rather their own, independent licensure. Here in Colorado, this license comes with an "acts allowed" section formulated by the licensing body. As stated, skills and assessments can be added so long as an MD has deemed the ATC competent.

For heat stroke patients, the ATC knows that immediate cooling is necessary and doesn't want to delay cooling measures any more than necessary. They'll institute cooling measures and call for EMS at an appropriate time so the athlete will be handed off to EMS very quickly and seamlessly. Actual conflicts between ATC's and EMS are pretty rare in my experience.

This is spot on, which is to be expected considering your background. My experience in my three years with Sports Medicine was that EMS and ATC conflicts came about purely as a result of the ignorance of the responding EMS crew. These were few and far between however. For the most part we had a great working relationship with local EMS and crews that worked with us frequently knew what our capabilities were and what they were needed for. Issues usually arose when we needed EMS at a non-covered event so the crew was not pre-briefed.

The ATC calling EMS does not indicate that he is in over his or her head with the patient but rather that the patient needs a higher level of care than he can provide. EMS is there to transport the patient to such care and provide interventions that the ATC does not have, which are generally in the realm of ALS providers.