This research indicates a greater need for education and the adoption of comprehensive Emergency Action Plans (EAP) which require: access to automated external defibrillators (AED), cardiopulmonary resuscitation (CPR), and epinephrine injections (EpiPens), and education and training around best practices for heat stroke prevention and care, cold weather and severe weather-related injury prevention and care, and concussion treatment and care (together, the “Ideal EAP”). This research indicates that a statute (Exhibit A) aimed at implementing the above-listed equipment and resources would reduce the number of injuries that occur during sports activities at the youth and high school levels and decrease the cost associated with such injuries. In an effort to incentivize the Ideal EAP, the statute will also provide enhanced immunity from liability to persons who make good faith efforts to assist those in need of emergent care.
Methods
This project draws from third-party resources, government data, and the expertise of John J. Leddy, M.D., a concussion specialist, and Leslie J. Bisson, M.D., an orthopaedic specialist, both of the University at Buffalo Jacobs School of Medicine and Biomedical Sciences. Dr. Bisson also serves as the team physician for the Buffalo Bills and the Buffalo Sabres of the National Football League and the National Hockey League, respectively.
Results
The findings of this research are crucial to American sports communities. The equipment components of the Ideal EAP (listed above) will be discussed individually. It will be shown that implementing the Ideal EAP would reduce the number of injuries that occur during sports activities at the youth and high school levels. Targeting these levels of sports will have a broad impact and will protect youth participants who do not have the benefit of the medical resources available at the collegiate and professional levels. The existing apparatus of state oversight for youth and high school athletics provides a ready mechanism for implementing the Ideal EAP. Not only will injuries be mitigated, but costs associated with sports injuries will be cut. A comparison between the costs of “preparedness” with the Ideal EAP, versus “unpreparedness” without the Ideal EAP, will support a statute aimed at implementing the Ideal EAP.
I. AEDs and CPR as a Response to SCA
A. Introduction
SCA is a leading cause of death in the United States, claiming over 350,000 lives each year. In fact, SCA takes more lives each year than breast cancer, lung cancer, or AIDS. SCA can be mitigated and is a recoverable injury. It took Damar Hamlin’s widely publicized sudden cardiac event to call national attention to the perils of SCA. Hamlin is now an advocate for greater access to AEDs and CPR training. His story is the driver of this research; it is fitting that this paper begins by stressing the importance of greater access to AEDs and CPR training as part of the Ideal EAP.
B. SCA and Statistics
SCA is the sudden loss of all heart activity due to an irregular heart rhythm, causing the victim to collapse and become unresponsive. SCA can occur in people of all ages, including children and teens, regardless of one’s apparent good health. SCA is the leading cause of death in young athletes engaged in a sport. Yet, the risk of SCA increases with age.
Without immediate treatment, SCA can result in death. An estimated 1,000 people per day in the United States suffer from SCA. When SCA occurs outside of a hospital, it is a mostly fatal condition with an average survival rate of 9% in the United States. Put differently, 85% to 90% of people who suffer from SCA do not survive, often because resuscitation attempts start too late. Research also indicates that for every one-minute delay in resuscitation, the likelihood of survival falls by up to 10%. The stakes of a less than rapid response to a SCA event are extremely high.
With swift medical attention, it is possible to survive SCA. Emergency treatment of SCA includes performing CPR and administering an AED. In responding to a SCA event, one should check for the victim’s responsiveness and begin CPR immediately, while someone else should call 911 and locate an AED (which should be reachable within 3 minutes total). Once an AED is available, it should be administered. Effective CPR can double or triple the chance of survival from cardiac arrest, and SCA’s common rhythms tend to be “shockable” by an AED. While AEDs are expensive, and training in AED use and CPR administration takes some effort, the research shows that the cost of unpreparedness is much greater and more grave.
C. Costs Associated with SCA With and Without AED
In considering the statistics of SCA, and the extent to which AEDs and CPR can mitigate a SCA event, it becomes evident that these tools are crucial to the Ideal EAP. Including AEDs and individuals trained in AED use and CPR as part of an Ideal EAP can also decrease the costs associated with SCA.
The only effective treatment for SCA is through AED use. As noted above, for every minute without defibrillation, a SCA victim’s chances of survival decrease by about 10%. After the first few minutes without defibrillation, resuscitation attempts are often unsuccessful. At the most basic level, the cost of unpreparedness is the loss of a human life. It seems unfathomable to quantify a human life. However, costs, such as funeral expenses, potential lawsuits and legal fees, or lost wages could be used to value a person’s life. For example, on the low end of these costs, the average funeral ranges in price from $7,000 to $12,000 (average of $9,500).
AED application can nearly double a person’s chance of survival after out-of-hospital cardiac arrest; thus, reducing the potential of death and the costs that follow. The costs associated with owning and maintaining an AED are lower (see Figure 1 below). AEDs can range in price from $1,200 to $3,000, depending on the device. Training, accessories, and maintenance of AEDs can reach $3,000 over the life of the AED. The total cost of owning an AED can range from $2,665 to $6,285 with an average cost of $4,476. Used AEDs are often available for purchase at a lower price and some organizations offer grant programs for nonprofits, charitable organizations, or government organizations to receive AEDs at discounted rates or for free. It is notable that many venues will likely require multiple AEDs, thus raising these baseline costs. Regardless, the value of a human life, or even the costs associated with a person’s death are greater than the cost of owning an AED (e.g., average funeral cost alone is $9,500 versus average AED cost of $4,476).
Figure 1.
AED Cost Example, assuming an 8-year AED life.
Without the application of an AED, a person’s chance of surviving an SCA is low. Regardless of when an AED is applied, a surviving victim’s recovery will be a factor. The immediate and proper use of an AED can better a person’s recovery period and the costs associated with it. Current literature indicates that the direct cost of care for SCA patients who survive to the point of hospital discharge is $37,000. Individuals who survive SCA may also have ancillary costs such as potential legal fees, a need for long-term physical and/ or psychological care, and other medical costs, thus drastically increasing recovery expenses. AED use will reduce these costs to the extent that they can be diminished.
The cost of AED and CPR training and certification is relatively modest compared to that of purchasing an AED. Often, the two trainings are completed in a single course. For example, the American Red Cross offers an adult and pediatric First Aid/CPR/AED training for $117. Other authorities offer certifications for as low as $15. In examining these costs, it is clear that when someone suffers from SCA, and there is not a measured response, the costs associated with recovering from the injury are immense.
In sum, with proper CPR administration and AED deployment SCA victims will either: (1) survive, avoiding the immense costs associated with death; or (2) recover, but with a better outcome and thus, a cheaper recovery in the long run.
D. Support for Model Law
There is a definite need for all sports venues to be equipped with AEDs and AED and CPR trained individuals. When venues equip themselves with these tools, the long-term cost of being prepared is significantly lower than that of unpreparedness. Ideal EAPs comprising AEDs and AED and CPR trained individuals will (1) reduce the number of injuries that occur during sports activities at all levels, and (2) decrease the cost associated with SCA. This supports a statute aimed at increasing access to AEDs and CPR.
II. Use of EpiPens as a Response to Anaphylaxis
A. Introduction
With more than one hundred million Americans dealing with allergies each year, allergies have become a prevalent issue. While most allergies merely result in a runny nose and itchy eyes, some allergic reactions can be life threatening. Anaphylaxis is one such potentially life-threatening reaction that can have severe consequences. The most common causes of anaphylaxis are food allergies and insect stings. Food allergies impact roughly one in every thirteen children in America. Insect stings, on the other hand, affect roughly 5% of Americans.
In considering the United States population, the number of people affected by severe allergic reactions is relatively trivial. However, on a smaller scale, sporting event attendees are surrounded by many different factors that have the potential of causing severe allergic reactions. People attending sporting events are susceptible to allergic reactions from foods and insect stings. Thus, the chance of encountering an allergen at a sporting event is increased dramatically compared to other environments. Players, coaches, and fans all have the potential to be subject to potential life-threatening allergic reactions at sporting events.
As previously mentioned, allergic reactions can be fatal without immediate treatment. EpiPens provide a relatively cheap, yet effective, way to reduce the potential life-threatening effects of anaphylaxis. The carrying and use of EpiPens at sporting venues would allow players, coaches, and fans alike to significantly increase their chances of survival if suffering from anaphylaxis.
B. Statistics
Anaphylaxis is a severe, life-threatening allergic reaction that can occur within just minutes of exposure to an allergen. It is a process in which one’s immune system attacks an allergen. This can cause the body to go into shock and result in a variety of other immune system responses. An anaphylactic response often requires hospitalization. Over the last 20 years, anaphylaxis has increased dramatically; specifically, anaphylaxis from food allergies has doubled in the last 10 years.
Researchers have estimated that about two to five percent of Americans experience anaphylaxis. They also found that many patients were not prepared with an EpiPen to combat the effects of the allergic reaction. Allergic reactions can happen quickly and have numerous causes. The most common triggers of anaphylaxis are peanuts, milk, eggs, seafood, and insect stings or bites. It takes about 30 minutes for someone with a food allergy, 15 minutes for someone with a venom allergy, and 5 minutes for someone with a medication allergy to experience respiratory or cardiac arrest due to anaphylaxis. A speedy response is crucial during an anaphylactic episode, and the only way to help someone experiencing anaphylaxis is through the use of an EpiPen.
An EpiPen is an auto-injector that injects epinephrine. Epinephrine is the first line of treatment and is the only medication proven to stop a life-threatening allergic reaction. The use of epinephrine helps relax muscles in the airway to make breathing easier and helps reverse the dangerously rapid decrease in blood pressure. People who are aware that they have severe allergies usually carry an EpiPen with them. However, not everyone has access to an EpiPen or is aware that they have a severe allergy to something.
EpiPens must be prescribed by a doctor. In a 2022 survey it was found that of the adults surveyed with food allergies only 52% of them were prescribed an EpiPen. This leaves people who do not have a prescription left hoping they don’t suffer a serious allergic reaction. Requiring venues to carry EpiPens, and allowing them to purchase EpiPens as part of the Ideal EAP without a prescription, will reduce the number of allergy related deaths each year. It will also increase the survival rates of people who suffer an anaphylaxis episode that do not have access to an EpiPen. There have been efforts at the state and federal level to allow for the over-the-counter purchase of EpiPens, and we recommend continuing to push for this legislation.
C. Costs Associated with Anaphylaxis with and without EpiPen
The costs associated with anaphylaxis are significantly higher when an EpiPen is not used versus when it is used. In addition to increasing people’s chances of survival, venues will also help mitigate the costs associated with an anaphylaxis episode.
The average cost of an EpiPen is roughly between $650 and $700. Accessing an EpiPen is a major barrier to many people. The ultimate price to pay for lack of resources, and in this case lack of EpiPens, is the death of a player, coach, or fan who is suffering from anaphylaxis. However, this cost can easily be avoided if the appropriate preventative measures are taken.
Even with an EpiPen, a person suffering from anaphylaxis will have to be taken to the hospital. An anaphylaxis hospitalization cost is estimated around $21,897. These expenses come from the cost of an ambulance ride, blood tests, and the need to see allergy specialists. However, such costs can be dramatically reduced if an EpiPen is rapidly deployed. It is clear that having access to EpiPens through the Ideal EAP will help mitigate costs substantially for people suffering from severe allergic reactions, as well as increase survival rates.
D. Support for Model Law
Cases of anaphylaxis are often forgotten when it comes to sport emergencies. However, sporting venues are exposed to outdoor variables and foods of all types – both leading causes of anaphylaxis. Pushing for venues to be allowed to purchase EpiPens without a prescription will provide everyone at the venue access to an EpiPen. Including EpiPen access under the Ideal EAP will lead to greater chances of surviving anaphylaxis and significant medical bill savings.
III. Heat Stroke and Heat Exhaustion
A. Introduction
Many current and former athletes are familiar with grueling conditioning practices. Coincidentally, these practices always seem to come on the hottest summer days. After these practices, players might joke that they thought they were going to “have a heat stroke.” Although this may be a joke to make light of the situation, heat illness is a major concern for all athletes.
In 2001, Minnesota Vikings pro-bowl offensive lineman, Korey Stringer, died of a heat stroke during practice. In response to Korey’s death, his wife, Kelci, started the Korey Stringer Institute. The Korey Stringer Institute works to prevent exertional heat stroke in Korey’s honor. Korey’s story and the work of the Stringer Institute played an important role in the decision to include heat illness prevention and treatment education as part of the Ideal EAP.
Heat illness is one of the most common emergency medical conditions and is one of the leading causes of death and disability among U.S. high school athletes. It can cause the body to shut down and lead to cardiac arrest. Educational initiatives for heat illnesses are inexpensive and can be the difference in a life-or-death situation. Athletes at all levels, and in all sports, regardless of its season, are at risk for heat illness. Coaches need to be educated about heat illness prevention and treatment. As it relates to heat illness, the Ideal EAP will seek to implement educational requirements, specifically addressing heat stroke and heat exhaustion. This will play a pivotal role in keeping athletes safe and help minimize post heat illness rehabilitation costs.
B. Statistics
Heat illnesses include a multitude of illnesses that occur because of heat exposure. Side effects of heat illnesses can range from minor cramping to death. However, there are steps that can be taken to prevent heat illnesses, such as proper hydration and heat acclimatization or body cooling. In the case of exertional heat stroke, which is common in athletes, delay in treatment nearly always results in long term complications or death.
Heat stroke is the most serious heat-related illness and occurs when the body can no longer control its temperature. The body’s sweating mechanism fails, its temperature rises, and the body is unable to cool down. A person’s body temperature can rise to 106°F or higher in less than 20 minutes. If the person does not receive emergency treatment immediately, heat stroke can result in permanent disability or death.
Heat exhaustion is the most common and mildest form of heat illness. Exercising in hot weather results in a lack of blood being pumped to the heart, which leads to energy depletion and possible physical collapse. The inability of the heart to pump oxygen to the body can be exacerbated by dehydration.
There is an estimated average annual number of 9,237 time-loss heat illnesses that occur among U.S. high school athletes. The highest rate of time-loss heat illness was among football players, 4.5 per 100,000 athlete-exposures, a rate 10 times higher than the average rate, which is 0.4, of eight other sports. Heat illnesses most commonly occur during preseason football practice, whether that be high school or college football. In the years 2000 to 2018, there were 30 deaths of National Collegiate Athletic Association (NCAA) college football players due to heat stroke. Although it is most likely to occur in football, other sports are also subject to the risk of heat illnesses.
Douglas Casa, CEO of the Korey Stringer Institute, stated that heat stroke is the third-most common cause of sudden death among high school athletes behind cardiac arrest and traumatic brain injuries. According to the National Center for Catastrophic Sport Injury Research, 67 high school athletes have died from exertional heat illness since 1982. Of that, 52% happened in August during the opening weeks of fall sports seasons, and almost all of the deaths, 94%, were football linemen. According to Casa, all heat-related deaths are entirely preventable with the right planning and minimal resources in place.
A 2020 study found that exertional heat stroke had a 100% survival rate when immediate cooling, such as cold water immersion or constant cold water dousing, was initiated within 10 minutes of collapse. Additionally, those that survived who were cooled with an insufficient cooling rate had a 4.57 times risk of medical complications compared to patients who were treated by adequate cooling methods. There were no patients that died when treatment included an adequate cooling rate, while 23 patients died with insufficient cooling. Additionally, 117 patients survived with medical complications when treatment involved an insufficient cooling rate, whereas, only 4 patients had complications with adequate cooling.
To reduce the risk for heat illness, athletic programs should be implementing preseason heat-acclimatization guidelines and encouraging proper hydration before, during, and after sports activity. Heat acclimation is beneficial to exercise in the heat and allows the body to better handle the heat stress your body is under. Additionally, the Ideal EAP will require there to be cold water and/or ice on standby at all times during events. The Ideal EAP will provide proper education of what signs to look for and advise on sufficient treatment methods, which will give all athletes a safe environment to play the sport they love.
C. Costs Associated with Heat Illness
Coaches and trainers need to know how to properly acclimate athletes to the stress of training in the heat, recognize heat illness warning signs, and know how to treat heat illnesses. The costs associated with preparing to treat heat illnesses are minimal. The only “equipment” needed to treat heat illnesses is a large tub, water, bags of ice, fluids, and electrolytes. When players begin to show signs of a possible heat illness, their body temperature needs to be cooled down immediately. This can be done by submerging the athlete in ice water or by covering them with bags of ice. This is a cost-effective solution for something that has the potential to result in death. The costs of preparation could range from $0 to roughly $100, depending on which supplies are purchased.
Furthermore, failure to prepare and be equipped with the proper treatment methods may result in extensive medical bills. In a study, the U.S. Army found that the outpatient costs of heat exhaustion treatment ranged from $3,024 to $4,327. The inpatient cost of heat stroke ranged from $5,000 to $6,878 per encounter.
In 2018, Jordan McNair, a 19-year-old football player at the University of Maryland, suffered from a heat stroke – his core body temperature soared to 106 degrees during a workout. McNair was not placed in an ice bath while waiting for emergency personnel and died 15 days later. Dr. Douglas Casa stated that, “[a] tub, ice and water would have saved [McNair’s] life [–] [i]t will save [a] life, every time.” The inexpensive preparedness cost of a tub and ice is all it takes to save an athlete’s life.
D. Expansion of Awareness of Weather-Related Risks to Extreme Cold and Severe Weather-Related Events
1. Indoor Events versus Outdoor Events
As weather patterns continue to change and more extreme weather seems to be becoming the norm, there needs to be an increased awareness of the dangers of not just exertion in extreme heat, but of exertion in extreme cold. A comprehensive EAP should also address the dangers associated with travel in inclement weather. Guidelines for the cancelation of school or club athletic events can be seen as falling into two broad categories – those related to indoor venues, for which travel in inclement weather is the greatest danger, and outdoor venues, for which participating in the activity itself is the danger. For inside venues, a sensible approach, given that privately operated venues such as ice rinks may not close due to inclement weather, is to tie school or club participation to local government guidance and/or local school closure policies for snow and other extreme weather. For example, if a local municipality issues a driving ban based on snow forecasts, a comprehensive EAP will call for the cancelation of athletic events requiring athletes travel to the venue. This takes the locus of control out of the hands of coaches and players and provides a bright line rule.
2. Extreme Cold Guidelines
A comprehensive EAP would provide guidance on when to cancel or suspend outdoor athletic events because of cold weather, and would also provide guidelines for best practices for the treatment of cold-weather injury. The following guidelines have been adapted from the National Athletic Trainers’ Association (NATA) and mirror guidelines adopted by major NCAA Division I athletic departments for cold weather athletic competition.
3. Sample Cold Weather Policy for Practice and Competition
The following temperatures are “Real Feel” temperatures and are determined by wind speed and ambient air temperature. A “Real Feel” measurement can be obtained on sites such as AccuWeather.com.
a) 30⁰F and below: Be aware of the potential for cold injury and notify appropriate personnel (i.e. athletes, support staff, coaching staff) of the potential for cold injury. Continuously monitor conditions and consider moving into a warmer environment such as a field house or indoor track.
b) 25⁰F and below: Provide additional protective clothing; cover as much exposed skin as practical; and provide opportunities and facilities for re-warming inside or in heated tents. For some sports, such as baseball, softball, and lacrosse that are not typically played in extreme cold, the recommendation is to monitor practices at these temperatures and to cancel competitive games if the temperature is below 25 degrees at game time – teams may take warm-ups if the weather appears to be warming up to an hour before game time.
c) 15⁰F and below: Consider modifying activity to limit exposure or to allow more frequent chances to re-warm.
d) 0⁰F and below: Recommended to terminate activity.
4. Education Surrounding Cold-Related Injuries
Coaches and athletes should be educated about the dangers of cold-related injuries in the same manner that they are educated about heat-related injuries. The Ideal EAP will contain information about how to quickly evaluate and treat cold-related injuries. Coaches who are outside with their athletes in cold weather should be attuned to the dangers and athletic trainers should have dry clothing and blankets accessible. Cold-related injuries range from mild hypothermia to frostbite, and injury is dependent on both the temperature of the air or water and the wind’s influence on the body’s ability to maintain a homeostatic state. The “Real Feel” temperature takes both factors into account. The most important thing to remember is to call EMS immediately in the case of severe hypothermia.
As with heat-related injuries and illness, there are simple, cost-effective preventative measures that coaches and trainers can educate their athletes on to help avoid cold-related injuries. It is recommended that athletes acclimate to cold weather through progressive training. Other preventative measures include: (1) dressing in wicking layers, (2) ensuring proper nutrition and hydration, as depleted energy stores can increase susceptibility to cold-related injury and athletes may not intuitively perceive thirst in cold weather, (3) ensuring adequate rest as sleep deficits increase the risk of hypothermia, (4) counseling athletes to avoid alcohol, nicotine, caffeine, and other drugs that cause vasodilation or vasoconstriction as well as water loss, and (5) ensuring proper warm-ups close to competition times with the availability of warm clothing to wear until actual competition beings following warm up.
E. Discussion of Support for Model Law
The Ideal EAP will serve as a guideline for schools and entities that wish to provide the safest possible environment for their athletes. The heat illness and cold weather/extreme weather educational requirements and treatment advice provided should be implemented at all athletic venues. This will ensure that athletes’ safety is the number one priority and will result in a reduction in weather illness related injuries, expenses, and even fatalities.
IV. Concussion Treatment and Care
A. Introduction
If you have played sports, or have been a sports observer, you may have experienced, or witnessed someone else experience, a concussion. While it can be jarring to experience or witness a head trauma, even more jarring is the often-unobserved aftermath to the injury. Concussions can have long-term, severe consequences that should be mitigated when possible.
In the last one hundred or so years, the body of knowledge surrounding concussions has grown immensely. For example, in 1893, the first leather football helmet was worn by a player in the Army-Navy game. However, it was not until 1939, some 46 years later, that the NCAA would require all football players to wear helmets. Over the remainder of the twentieth century, as concussion science advanced, so too did football equipment and safety protocols. Now, each of the NCAA’s conferences requires their member schools to submit for NCAA approval a policy for detecting a concussion and return-to-play protocol. This is reflective of the fact that today concussions are a well-known injury. The current understanding of concussions has resulted in greater safety protocols for athletes. Including concussion treatment and care as part of the proposed model law and Ideal EAP can be another notch on the concussion timeline, resulting in greater protection of athletes.
B. Statistics
A concussion is: (1) a change in brain function, (2) following a force to the head, which (3) may be accompanied by a temporary loss of consciousness, but is (4) identified in awake individuals, with (5) measures of neurologic and cognitive dysfunction. A sport-related concussion (SRC) is considered a mild traumatic brain injury (mTBI) sustained during sports. Usually concussions have short-term effects, that when properly managed, can be completely recovered from in a relatively short period of time. The long-term effects of concussions are less certain, but in some cases, can result in long-term memory issues such as irritability, ringing in the ears, and light sensitivity.
Concussions are an all-sport issue. An estimated 3.8 million concussions occur each year in the United States from sports-related injuries. The Center for Disease Control (CDC) estimates that 5% to 10% of athletes will experience a concussion in any given sports season. In 2019, roughly 15% of all U.S. high-school students self-reported one or more sports or recreation-related concussions within the preceding 12 months. Each year, more than 170,000 kids and teens are treated in an emergency department for sports or recreation-related traumatic brain injuries. The impact of concussions on youth is immense, and young children and teens are more likely to get a concussion and take longer to recover than adults. There are also sex-related differences as it relates to concussions. In male sports, most concussions were caused by player contact; female sports, however, saw more concussions caused by contact with equipment. This injury impacts people of all ages, and all sports (though, some more than others). The bottom line is that greater measures are needed to decrease the amount of sports-related concussion injuries. Including concussion treatment and care as part of the Ideal EAP can be a great step towards this much needed shift.
C. Costs Associated with Concussions
The costs associated with a concussion are much lower when prepared, as opposed to unprepared, to diagnose and treat them. Athletic venues can both mitigate the chances of, and decrease the costs associated with, concussions by including educational materials for concussion detection, treatment, and care in their Ideal EAP.
A recent study found the average direct healthcare costs of a concussion are $800. It was found that the more symptoms an athlete had at their first medical visit, the higher total cost of care. Yet, another study set the average follow-up cost for mild traumatic brain injuries at $13,564.
Contrastingly, the cost of educating oneself about preventing, diagnosing, and treating concussions can range from $0 to $950, with an average cost of preparedness being $475. A doctor donating their time to educate and provide concussion related materials to a venue or team could easily bring the costs closer to $0. Or, the purchase of educational materials could raise the price, but still be relatively low to the potential medical costs associated with recovering from a concussion. Moreover, including concussion knowledge as part of the Ideal EAP will ensure earlier detection of concussions when they do occur, and will lead to quicker treatment and a better recovery. It should be noted that equipment changes could impact the prevalence of concussions. However, equipment will not be addressed as part of the Ideal EAP discussion as it can vary greatly by sport.
D. Discussion of Support for Model Law
Many concussions go unreported and undiagnosed, leading to mismanagement and premature return to activity. Including concussion education as an element of the Ideal EAP will ensure best practices in coaching, reduce concussions, and increase the chances of detecting and reporting concussions. Thus, it makes sense that concussion protocol be included as part of the model law and Ideal EAP. As an aside, New York does currently have a concussion management statute, the Concussion Management and Awareness Act. This model law, if enacted in New York, would propose that the current concussion statute be folded into the prospective new statute. This would ensure all pertinent information is found in one place, thus eliminating possibility for confusion or lack of clarity.
Emergency Action Plans
The above measures call for quick, constructed responses, which support a statute requiring the development and implementation of EAPs for venues at which athletic activities occur.
I. Constructing a “Kit”
The components of the Ideal EAP, as discussed above, include both educational materials and emergency response equipment. The emergency response capabilities – AEDs, CPR, EpiPens, general first aid (such as tourniquets and Narcan), heat stroke and severe weather care, and concussion care – can be conceptualized as a package or kit (together, a “Kit”). The educational materials and requirements can then be thought of as “manuals” to the Kit. Additionally, the Ideal EAP will also include an overarching explanation as to how the pieces of the Kit should be employed in an emergency situation (the entirety of these components are still considered the “Ideal EAP”).
Starting with a broad, general structure, the Ideal EAP will be specifically adapted to each venue or sports program that seeks to adopt its methods. In other words, the Ideal EAP will serve as a general guideline, but individualized plans will be customized based upon the needs of each venue. This method will ensure maximum effectiveness of the Ideal EAP and will provide athletes with the safest possible environment. For example, AEDs should be reachable within 3 minutes of any emergent situation (90 seconds out and 90 seconds back). Venues should strive to adhere to this timeframe, and doing so may require a greater number of AEDs. Thus, venue layout may dictate the extent of equipment needed.
The model law and the Ideal EAP will have a default provision that venues are responsible for assembling, providing, and maintaining the Kits. This is logical in that the venue itself will know the best places where the Kits and their components should be placed. However, depending on the venue type, in certain instances it may make sense for sporting participants (i.e., leagues, teams, or competitors) to supply aspects of the Kits. For example, perhaps the venue provides the educational material by way of banners and posters, but it may be more efficient for a team to bring the AED, first aid, etc. In these cases, participants will need to certify to the venue that they have satisfied their EAP requirements. Moreover, visitors of the venues will need to communicate with the venue ahead of time to implement venue specific protocol into their EAP.
The cost benefit analysis for each portion of the Ideal EAP above makes a case that it is overall cheaper to supply these Kits than not. However, actual costs will more accurately be set once venue specific needs are determined.
II. Ideal Kit Placement by Venue
Figure 2 (below) lays out different venue types, expected injuries, and where the Ideal EAPs should be located at each venue. This chart is meant to illustrate the components of the Ideal EAP by venue. There is some variation as to the venue requirements, as different venues have different needs. This reflects the above-discussed idea that the Ideal EAP can be customized by venue. For example, indoor stadiums (e.g., ice rinks) may have Kits or equipment located in designated areas, whereas the miscellaneous outdoor sports areas (e.g., a marathon) may have mobile “patrolling” Kits. This chart can guide venues and sports programs in the process of adopting and implementing the Ideal EAP.
It should be noted that all of the components of the Ideal EAP (AED/CPR, EpiPens. heat illnesses, concussions) fit into each facility, but to varying degrees. For example, a reader may think it unnecessary that heat illness protocol be included as part of an ice rink’s Ideal EAP. While rinks are cold, hockey players and other winter athletes are working hard and sometimes wearing a lot of equipment. As noted, heat illness can impact all sports. Moreover, the ice in rinks can often be converted to regular floors to be shared with basketball, lacrosse, or similar indoor sports.
The chart does not specifically address the location of educational materials relating to concussion protocol and severe weather illness treatment. This educational component of the Ideal EAP is something that could be permanently placed in a venue. For example, posters (think: Heimlich chart) could be placed near or in locker rooms, team benches (e.g., in a baseball dugout), and near various entrances to the venues. Finally, the “Equipment” column requires an ambulance presence. The only facility areas not requiring ambulance presence are training areas. This serves to distinguish between competition and practice.
Figure 2.
III. Recommendation for Designated Non-Coach Safety Person
While we do not envision this as a requirement of the Ideal EAP, we recommend that teams, especially those operating outside of the school-setting where athletic trainers are more common, designate a non-coach Safety Person as an additional enhancement for player safety. Drawing on the Hockey Canada Safety Person Program, designating a non-coach as responsible for evaluating injuries and for providing education to others in the organization about the Ideal EAP will ensure an added layer of protection for youth athletes. Hockey Canada now mandates that each team in each member organization have a designated Safety Person who is responsible for taking steps such as maintaining a comprehensive first aid kit, identifying the location of AEDs in arenas, identifying athletes with signs of a possible concussion, and evaluating injured athletes to assess if additional steps such as calling for an ambulance need to take place. A key feature of the Safety Person program is to designate a person for each game who is not on the bench, as the person who will make a 911 call if needed; the rationale is that coaches should be focusing on their other players and/or assisting the injured player. Creating a clear chain of command in the event of a serious injury prevents panic and can save valuable time. The Hockey Canada program mandates that the Safety Person complete a six-hour course on basic injury prevention, first aid, and risk management. While the course is hockey-specific, the concept of providing a designated non-coach volunteer with educational materials can be rolled into the Ideal EAP. Coaches and players alike are often not the best judge of when additional medical care is required and having an educated volunteer on hand for games helps ensure a proper response.
Limiting Liability
As an incentive for individuals and sports organizations at the youth and high school levels to adopt and use the Ideal EAP, this paper and the model law (Exhibit A) propose a limit on liability for those who offer aid in emergent situations. This limit on liability can be guided by New York’s Good Samaritan statute, which provides, in relevant part:
Any person who voluntarily and without expectation of monetary compensation renders first aid or emergency treatment at the scene of an accident or other emergency outside a hospital, doctor’s office or any other place having proper and necessary medical equipment, to a person who is unconscious, ill, or injured, shall not be liable for damages for injuries alleged to have been sustained by such person or for damages for the death of such person alleged to have occurred by reason of an act or omission in the rendering of such emergency treatment unless it is established that such injuries were or such death was caused by gross negligence on the part of such person.
The Good Samaritan law also limits liability with respect to use of AEDs and EpiPens. It provides that, subject to certain conditions, various individuals and entities will be not liable for damages arising from the use of first aid, AEDs, or EpiPens when such assistance was voluntary and without the expectation of monetary compensation.
Based on New York’s Good Samaritan law and the goals of the Ideal EAP, it is proposed that anyone taking reasonable steps to ensure athlete safety, even with respect to inclement weather of any sort, shall be exempt from liability unless they act with negligence (school or paid coaches, venue owners, and operators) or with recklessness (volunteers and bystanders). The two categories are meant to incentivize a range of people to intervene when necessary.
The proposed liability limits are divided into two categories: (1) those who are held to a negligence standard and (2) those who are held to a recklessness standard. The higher standard of negligence will apply to school or paid coaches, venue owners, and venue operators. Simply, the higher standard will apply to people acting in official capacities in lower-level sports. The recklessness standard will apply to volunteers and bystanders. This paper proposes a lower standard than New York’s Good Samaritan law for volunteers and innocent bystanders. The lower standard of recklessness seeks to incentivize greater action among individuals who otherwise might be afraid to act in emergent situations.
Further, no one shall be held liable for torts arising from AED use or even improper AED use. This is based on the fact that it is almost impossible to improperly use AEDs and seeks to mitigate public fear with respect to attempted AED use. This, too, seeks to incentivize greater action when it comes to life and death situations.
Conclusion
This project will be a tool for improving sports safety in communities across the country. Some might call Damar Hamlin’s case a miracle, but the emergency response by the Buffalo Bills medical team was pre-planned, pre-practiced, systematic, and efficient. The success of Hamlin’s story is thanks to the Bills medical team’s preparedness in executing their EAP. Widespread adaptation of the Ideal EAP will prioritize the health and safety of athletes at all levels (not just those who play in top leagues). The Ideal EAP represents the standard against which venues should model their EAPs. With this ideal protocol, hopefully successful outcomes like Hamlin’s become the norm.