ER Physician and Football

[traumasurg]

I work on an ambulance where I live and recently at a high school football game a player took a hit that looked harmless. One of the teams had an ER physician on their sidelines and he diagnosed that the player needed surgery immediately. The physician is the head of the ER dept at a local hospital and the player was taken there where he received emergency surgery to relieve the swelling on his brain.

The local paper recently posed the question..

What would it cost to have an ER physician at every high school football game?

I thought it was interesting and was wondering what you all would expect to be paid to spend 3-4 hours a high school football game?

---

Members don't see this ad.

 

[docB]

If you're really trying to pay someone to work a game as a team doc it'll probably take ~$200 to $500 per game. In reality for high school you could probably get a local group that would volunteer to do it for the cost of insurance. Now once it's an unpaid, volunteer situation it's going to get harder to staff because volunteers work when it's convenient, they don't change their plans to make time.

Another question is if it's really needed to have a doc, let alone and EP, at every game. No EP looked at the kid and decided he needed surgery without him having any symptoms. It's much more likely that the kid was initially fine then when he developed symptoms the EP sent him to the ED for a CT and he was then determined to have a bleed. Many types of providers can monitor for symptoms such as trainers, coaches, etc.

 

[traumasurg]

If you're really trying to pay someone to work a game as a team doc it'll probably take ~$200 to $500 per game. In reality for high school you could probably get a local group that would volunteer to do it for the cost of insurance. Now once it's an unpaid, volunteer situation it's going to get harder to staff because volunteers work when it's convenient, they don't change their plans to make time.

Another question is if it's really needed to have a doc, let alone and EP, at every game. No EP looked at the kid and decided he needed surgery without him having any symptoms. It's much more likely that the kid was initially fine then when he developed symptoms the EP sent him to the ED for a CT and he was then determined to have a bleed. Many types of providers can monitor for symptoms such as trainers, coaches, etc.

I was skeptical when I first heard from a coworker who was at the game. He said the player started seizing and that's when the EP decided to go to his ER with him.

I think that where I live the local government may be considering staffing each game with a physician but I had many questions about the things you addressed such as insurance and all that good stuff.

Thanks for the reply.

 

[thethom]

This is where the sports medicine physician "comes into play" (subspecialty fellowship after FM, PM&R, or EM residency). The problem is it will be impossible to have one at every single game, especially at the high school level. At my program we volunteer to cover the local universities and high schools, but even with all 3 sports med fellows covering as much as they can, and those of us residents who are interested in sports med covering other events, most of the events in the area still go uncovered. Its just logistically impossible to cover every event in an area with an MD on scene at all times, and often impossible for an often already financially challenged high school to pay for one at every game. Luckily events like the one aforementioned don't happen often.

 

[pagemmapants]

Yeah, we have sports med fellows at all our local high school football games, and some of the other sports as well such as v-ball, b-ball, etc. of course, not all hospitals have sports medicine fellows soooooo if they were to hire a community ER doc it might get quite a bit more expensive for questionable benefit considering the paucity of truly emergent issues on the field. Mostly our sports docs on-site just treat shin splints, minor fractures, heat exhaustion, and concussion and if it gets worse than that they call in the EMTs for transport. I think a smart high school student with a good "sports training" class under his/her belt could take care of that. They did at my own high school.

 

[traumasurg]

Yeah, we have sports med fellows at all our local high school football games, and some of the other sports as well such as v-ball, b-ball, etc. of course, not all hospitals have sports medicine fellows soooooo if they were to hire a community ER doc it might get quite a bit more expensive for questionable benefit considering the paucity of truly emergent issues on the field. Mostly our sports docs on-site just treat shin splints, minor fractures, heat exhaustion, and concussion and if it gets worse than that they call in the EMTs for transport. I think a smart high school student with a good "sports training" class under his/her belt could take care of that. They did at my own high school.

Yea I can see this probably works better with sports medicine fellows. I also help out with a local high school football team and our team doc is an ortho w/sports med and I have talked with him a lot about it. I could see this being very expensive to hire physician in a time where money is short. I doubt it will ever happen.

 

[jbar]

It also depends on what you mean by "high school football." I'm sure that there are some high school games down in Texas (the ones you see on ESPN) where you get like five to ten thousand people. If you have enough people there you start getting into large event coverage territory where having a physician on scene makes sense not so much for the players but because your chances of having someone code or have other badness go up when you have that many people

http://www.txprepsfootball.com/history.html

(to show I'm not talking out of my butt, here is a list of record attendance at Texas high school football games, all over 30,000 people.)

 

[WilcoWorld]

OK - I'm gonna flame here just a bit.

I think that having a cell phone (to call 911), a c-collar, and an AED on site are more important that a physician. If you need a doctor, chances are that in this day-and-age you also need a hospital. Take the example provided above - Wouldn't any layperson be able to recognize that if someone had a seizure after head injury he should be seen by a doctor? In that case you didn't need an MD to make that decision. Furthermore, if the facts are all as stated above, and a doctor decided with certainty that someone needed surgery because he had a seizure then that doctor was wrong. Even after selecting for patients who have had a seizure after head injury they are still more likely to have a non-operative injury then they are to require surgery.

All right, let it rain down on me now...

 

[thethom]

LOL no rains coming down on ya. You mentioned one case of head injury-> seizure-> craniotomy, but what about head injury cases where serious injury is not so obvious (MOST head injuries). Many just go home with terrible consequences, look at Natasha Richardson. What about a kid who goes home with a jumped facet. I nearly went home after a high school hockey game when the trainer/coach thought I dislocated my shoulder, pulled on it, saw no change, and figured I was fine. Ended up going to the hospital cuz it hurt too much and viola, had snapped my clavicle in two (granted it prob woulda healed ok anyways lol).

While covering college athletics I have had to throw in stitches a few times in the training room then get the kid back out to the field, this is just not something athletic trainers/coaches are proficient in.

Not saying every athletic event needs an MD, just saying at the higher levels it might be more helpful. I do not however think that any athlete (high school, college, or professional) should be entrusted with the diagnosis and treatment of a injury to him/herself.

Lastly, on-site event coverage is usually not paid, and thats why we have office practice as well. I do it because its fun and a nice way to get outdoors and do something fun with my girlfriend.

 

[Arcan57]

Agree with above (WW's point). I think having someone on the sidelines that has a basic understanding of concussion guidelines, c-spine immobilization as it relates to that particular sport, and the ability to contact 911 would provide most of the benefit of an EM or sports-medicine physician at a fraction of the cost. I'm know the textbook for such training exists (Sports Emergency Care: A Team Approach by Robb Rehberg PhD ATC NREMT).

 

[Old_Mil]

The local paper recently posed the question..

What would it cost to have an ER physician at every high school football game?

I thought it was interesting and was wondering what you all would expect to be paid to spend 3-4 hours a high school football game?

Assuming that there was some mechanism worked out for liability coverage, I'd be happy to do it for a reserved parking spot and free diet cokes. Just another way of giving back to the community, really.

 

[deleted65604]

I second Wilco's opinion.

I think a coach is fully capable of doing everything I would do if I were on the field. Game medicine is simple... watch out for head injury, c-spine injury, amd spleen/liver lacs (all of which are infrequent due to the amount of padding they wear). Other then that, you have extremity injuries, which are pretty straight forward... can't walk, or run on legs, then you can't play. Something looks deformed, or is painful, they should get it x-rayed.

The average coach is an athlete with decades of cumulative personal experience in sports and with sports injuries. The average ER doctor is a nerd who would start crying uncontrollably if they took a head-on hit from a college line-backer.

You don't have to be a doctor to learn everything there is to know about head-injuries and c-spine injuries. When all is said and done, if a coach has a worry, they just have the kid come in.

 

[atstudent]

There is a healthcare provider trained specifically in a lot of what you guys are talking about. Yes athletic trainers... At the high school I went to, we had an athletic trainer and at least one physician at all of the varsity games. The physicians were FP who had additional experience in sports medicine. They work great together and work hand in hand all the time. The physicians are volunteers who provide an excellent service to this community and have been doing so for a long time.

 

[boo2]

As a fellow who does high school and college football coverage, I think having a good athletic trainer is essential, however many budgets cannot even fund that. The disparity of resources at public schools is truly shocking and I never truly appreciated it until I spent time in an urban magnet school and an affluent suburban school, both public. So, if you feel like supporting the community, volunteering to staff these games is in reality good advertisement for your group, good community service(3hrs), and generally pretty fun.

I have a good athletic trainer who I work with and even they like to have us around to bounce ideas off of.

It is not a good idea to put return to play decision making to coaches. These decisions become second nature for us given our years of training and ability to form a "gestalt", which I think we sometimes take for granted. Even at the high school level adrenaline is pumping, and there is a lot of pressure to win and push yourself. Athletes are often told to "shake it off" and everyone is just trying to fit in.

One kid had a concussion with bad headache and visual changes, and the coach still sent him back in the game because he was a key player- they did not have an athletic trainer, and if they had one the kid most definitely would have been held out. This was despite my co-fellow's(who was covering the other team and technically had no authority over this team) strong warning against playing him.

People lose sight of the big picture and as physicians we add some objective decision making in the best interest of the athlete.

 

[WilcoWorld]

One kid had a concussion with bad headache and visual changes, and the coach still sent him back in the game because he was a key player- they did not have an athletic trainer, and if they had one the kid most definitely would have been held out. This was despite my co-fellow's(who was covering the other team and technically had no authority over this team) strong warning against playing him.

The way I see it, this story only serves to support my point that common sense is more important than a doctor's presence.

 

[thethom]

The way I see it, this story only serves to support my point that common sense is more important than a doctor's presence.

However your point puts the decision in a coach or trainer or other bystander, and assumes they have the "sense" that we doctors deem "common." As an athlete-> doctor, I know that is not often the case during a game...

Boo2 has a better idea it seems than the rest of you on what human resources are actually available at most high school events (not just football, yes there are other sports) and what an on-site MD adds. Read "The Injured Athlete" by Kulund, its an older book but still a classic text on Sports Medicine.

In addition, a sports medicine MD has more long-term responsibility than just sideline care, there's a reason that the specialty is called "Primary Care Sports Medicine."

 

[Jeff698]

I'm fascinated by how some of the threads on this forum pull in folks from so many other specialties.

I'm not trying to be a jerk, I'm really just wondering how this happens. Do y'all do searches on topics that might interest you or do you troll (not meant in a negative sense here) various fora looking for interesting stuff?

I haven't ventured outside of the EM forum in what seems like years so I really don't know what else is going on. Am I missing a new feature or something?

BTW, I think the real value in having a physician on the field isn't for the gorked players. Those are sort of obvious...call EMS. It's the not-so-obvious bong to the head that someone skilled in sports medicine (i.e. not me) would be able to asses then and there and say yea or nay on whether to continue or not. As with most things in medicine, it's the subtle stuff that's hard.

Take care,
Jeff

 

[thethom]

I have an interest in many branches of medicine, so I peruse a few forums. Also considering I'm interested in sports medicine, it would make sense for me to post on both the FM and EM forums (especially a thread entitled EMs and Football) right?

That being said Jeff, I think you have it right, its the subtle injuries that are key. Also since I may be seeing the injured athlete in the office afterwards I think seeing the mechanism of injury helps a lot.

Plus, Football, soccer, basketball, hockey games are FUN to watch (since I'm too old to play now lol)!

 

[boo2]

ummm...........i'm EM trained. no, i do not stalk other forums, just chime in when i feel i'm qualified to make an informed comment.

 

[docB]

Jeff wasn't trying to be disparaging. Sometimes it is interesting what threads bring in folks from other areas or draw the lurkers out of hiding. This additional input is appreciated and gives the board depth.

There are some people who have set it up to get email notices of action on particular threads and there are certain topics that when they pop up as thread titles on the main board bring in people who care about those particular issues.

 

[nick89302]

Why not an ALS ambulance instead? It would surely be less expensive than a physician and it would provide the means to safely transport an immobilized patient. There would also be the added coverage for the fans as well.

 

[thethom]

ummm...........i'm EM trained. no, i do not stalk other forums, just chime in when i feel i'm qualified to make an informed comment.

🙄

 

[boo2]

In most cases I don't think there is direct money in it for physicians. As I said before its a service for the community and gets your group advertisement, and potential business if there are injuries. Unlike the big money pro teams where you are paying to cover them for the advertisement.

Whether or not its "worth" the time of a physician its debatable, but there is an increasing number of sports requiring it, and some of them do pay which is just gravy if you enjoy the sport as well.

The BLS/paramedic units are paid.

 

[Aerin Sol]

Why not an ALS ambulance instead? It would surely be less expensive than a physician and it would provide the means to safely transport an immobilized patient. There would also be the added coverage for the fans as well.

That's what I thought.

 

[Jeff698]

Jeff wasn't trying to be disparaging. Sometimes it is interesting what threads bring in folks from other areas or draw the lurkers out of hiding. This additional input is appreciated and gives the board depth.

Exactly. I hope I didn't imply that I don't value the insight I get from our non-EM colleagues when they post here. If I did, it certainly wasn't my intent.

Take care,
Jeff

 

[KD1655]

In New Jersey, I believe that the NJSIAA (New Jersey Sports Interscholastic Athletic Association), which is the sanctioning body for all HS sports in the Garden State, requires a physician, a BLS ambulance, and an athletic trainer to be present at all varsity football games. I have worked on the ambulance at a number of HS football games (as a volunteer in my home town which meant free admission into the game and as a paid EMT at my career EMS jobs which meant overtime 😀). I have never had an injury to a player while working EMS that required the services of the physician, much less the ambulance. However, as a player in high school, my buddy and I "pancaked" an opposing player and knocked him out cold. The player's team mates, not knowing that he was unconscious, tried to help him up but he was dead weight; they continued trying to drage him off the field. While this was before any of my formal EMS training, I could surmise that probably was not the best thing for the player. The kid was unconscious for the entire time that he was being assessed and did not regain consciousness before being whisked away by the ambulance. Knowing what I know now, that patient required ALS interventions by paramedics as well as the physician. During my college playing days, a team mate of mine got his foot stuck on the turf as he planted and tried to cut and got hit at that exact second. The awkward angle coupled with the force of the hit resulting in a BADDDDDD compound/angulated tib/fib fracture to the point that the huys toes were pointing the wrong way. The team physician was a orthopod and quickly assessed the lack of blood flow to the distal extremity. He determined that he had to "set" the fracture immediately without any pain management and proceeded to do so on the field. I was standing a good 50+ yards and heard the awful screams as if I were right next to him.

With regards to a high schools' responsibility to provide a physician, BLS bus, and athletic trainer at varsity football games, the "home" team is responsible for providing these medical services. Most teams/schools retain their own athletic trainers but I have yet to see a public school that employs a full-time physician. With regards to compensation for the doc, I got to talking to the doc at one of my paid EMS football gigs; he said that he was an IM trained physician that had done a sports medicine fellowship and I think that he said he got ~$200 for the game. In my opinion, the school got a deal because he had a sports medicine fellow that he was training with him and the fellow was not compensated by the school.

 

[gro2001]

One advantage of having a physician present to evaluate those bumps to the noggin, as opposed to leaving the decision to the coach, is that (if football coaches are at all similar to some rugby coaches I know) a coach may have a conflict of interest: a key player gets hit on the head, seems ok... although the best thing to do would probably let the player sit out at least for a little while, at a crucial point in the game the coach might push the guy to get back in the game. Or at least let the guy back in if the athlete feels up to it. A physician, apart from being better equipped to evaluate subtle injuries, also has less pressure of letting an athlete in questionable status play.

 

[edgesofsanity]

One advantage of having a physician present to evaluate those bumps to the noggin, as opposed to leaving the decision to the coach, is that (if football coaches are at all similar to some rugby coaches I know) a coach may have a conflict of interest: a key player gets hit on the head, seems ok... although the best thing to do would probably let the player sit out at least for a little while, at a crucial point in the game the coach might push the guy to get back in the game. Or at least let the guy back in if the athlete feels up to it. A physician, apart from being better equipped to evaluate subtle injuries, also has less pressure of letting an athlete in questionable status play.

In my experience, it's the player who wants to cover up the extent of the problem and get back in the game - the coaches are usually the ones who send the guys over for me to evaluate.

Don't forget - the first thing you do when evaluating a player is take their helmet away.