Drs Konin, Morris, Coris, and Pescasio are from the Department of Orthopaedics & Sports Medicine, Dr Liller is from the Graduate School, and Dr Carey is from the College of Medicine, University of South Florida, Tampa, Fla. Dr Konin is also from the Department of Public Health, and Drs Coris and Pescasio are also from the Department of Family Medicine, University of South Florida, Tampa, Fla.
Financial support for this study has been provided by the State of Florida as part of the Sports Medicine & Athletic Related Trauma (SMART) Institute.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Barbara Morris, DHSc, ATC, CSCS, ROT, University of South Florida, Department of Orthopaedics & Sports Medicine, 13220 USF Laurel Drive, MDF 5th Floor, MDC 106, Tampa, FL 33612; e-mail: firstname.lastname@example.org.
Football in the state of Florida is perhaps the most popular of high school sports. Weekly games draw large crowds, establish long-lasting annual rivalries, and create a media buzz unlike that seen in many other states. The Florida High School Athletic Association (FHSAA) reported an increase in high school athletic participation for the 2006–2007 school year, specifically identifying 11-player tackle football as the most popular sport in Florida for boys with a total of 38,744 participants.1 Accompanying the attention that football draws is an unequaled prevalence of injuries. Comstock et al2 determined that football had the highest incidence of injury among high school-aged participants, reporting 4.36 injuries per 1,000 athlete-exposures for the 2005–2006 school year.
Many organizations have made suggestions regarding adequate medical coverage for secondary school sporting event sidelines. Almquist et al3 recommended that an appropriate health care team be identified for individual secondary schools. A certified athletic trainer is recommended as the allied health care provider to deliver on-site medical care to secondary school student athletes.3 The National Athletic Trainers’ Association (NATA) in its “Secondary School Official Statement” stated that student athletes should receive immediate care for injuries and recommended that all secondary schools provide a full-time, on-site certified athletic trainer to its student athlete population.4
In 1989 and again in 2007, The American Academy of Family Practice (AAFP) encouraged high schools to incorporate certified athletic trainers as part of the high school athletic program.5 Recently, Casa et al6 argued that a certified athletic trainer or team physician are the only individuals prepared to address life-threatening situations and suggested that coaches do not have the appropriate training and thus should not assess injured athletes. Despite the documented high incidence of injury rate and recommendations suggested by medical organizations, guidelines for medical coverage during high school football games are not standardized within Florida or the United States.
Nass7 surveyed high schools in Wisconsin to ascertain sports medicine coverage at interscholastic athletic events. A follow-up survey approximately 9 years later revealed only a slight expansion of medical coverage over that time. Medical coverage at high school football games was provided by a physician at 45% of schools, athletic trainers at 67% of schools, and ambulance personnel at 71% of schools.8
Reports of medical coverage in other states demonstrate a similar trend of inconsistent care. A study in North Carolina found that 73% of the state’s athletic directors felt that the medical coverage for their high school athletic events was inadequate.9 In 2006, 74% of high schools surveyed in North Carolina had ambulance coverage at high school football games. Seventy-eight percent of high schools reported some physician coverage at high school athletic events, 52% of these schools using orthopedic surgeons and 35% using primary care physicians. In addition, 51% of the schools had access to a nationally certified athletic trainer.10
A survey of southern California high schools revealed that only 37.5% of schools had an ambulance available at home football games, and 24.2% of schools had one on standby call with a physician present 72.2% of the time. Furthermore, 69% of high schools reported having a dedicated trainer, defined as an athletic trainer who provided sports medicine coverage only at football games.11
In 2004, 89.4% of Chicago, Illinois, public high schools had paramedics at football games, whereas only 10.6% of Chicago public high schools had physicians present at home varsity football games and 8.5% used certified athletic trainers.12 In the state of Illinois, Bell et al13 reported 43% of schools having a physician available for athletic events, 21% of whom were orthopedic surgeons. In the same study, 72.9% of high schools in Illinois had an athletic trainer available for athletic events.13
To our knowledge, no previous studies in the state of Florida have been conducted to investigate the status of medical coverage at high school football games. The purpose of this survey was to report the findings of high school football medical coverage status in the state of Florida as identified through a survey of athletic directors.
Materials and Methods
A total of 632 surveys were mailed to athletic directors of all public and private schools that offer football programs as identified by the FHSAA. The survey consisted of 6 questions regarding the type of medical personnel used for football games, as well as payment for their services. Returned envelopes were coded and recorded by a third party unfamiliar with the study goals. This third party individual subsequently mailed a second request to athletic directors who did not complete and return the survey within 60 days of the initial mailing. The survey consisted of multiple choice questions requesting the status of medical coverage at high school football games. Two certified athletic trainers with expertise in the planning of high school football medical coverage reviewed the survey for readability. Approval for this study was obtained through the university’s institutional review board.
Twenty-nine percent of surveys were completed and returned (N = 186). Seventy-one percent (n = 129) of the athletic directors listed having an emergency medical technician or a paramedic working at the football game and 77% (n = 139) stated having an ambulance present. In terms of physician support, athletic directors noted that their schools used a family medicine physician (34%) or an orthopedic surgeon (59%) most often, with some schools having both (23%). Seventy-six percent of completed surveys indicated that high school football games are supervised by a physician, and 69% require an emergency medical technician or a paramedic to be present. Many of the athletic directors reported some combination of physicians, certified athletic trainers, and emergency medical personnel (eg, emergency medical technicians, paramedics) as providing coverage. Forty-three athletic directors (23%) reported that they do not have a physician on the sideline during football games, of which 30 (70%) indicated that primary care was provided through an emergency medical technician or a paramedic. Seventy-nine percent (n = 129) of the athletic directors surveyed indicated that the school receives services from a certified athletic trainer. Thirty-four percent of the surveyed athletic directors reported no medical coverage at high school football games. The reported medical providers used for high school football game coverage are identified in the Figure.
Figure. Type of medical coverage provided at Florida high school football games (%). (Abbreviations: EMT, emergency medical technician; ATC, certified athletic trainer.)
The results of this survey demonstrate that medical coverage for high school football games in Florida as reported by athletic directors is inconsistent. No standardized or regulated care is required by an organizing body, leaving it up to each high school administration to make its own determination of how to provide on-site medical care for high school football games. A limitation of the study is that only 29% of surveys were returned from high school athletic directors. This number is less than that reported in other research using surveys.14,15
FHSAA, the governing body for secondary school athletic participation, includes a medical advisory board that provides oversight for sports safety. Neither this group nor the state association mandates a specific level or provider of coverage for high school football games. As such, athletic directors in our study reported the following professionals as standard components of football game coverage: chiropractors (10%), nurses (2%), podiatrists (1%), dentists (1%), physician assistants (5%), massage therapists (1%), and physical therapists (12%). The physician coverage reported included both primary care (family) physicians (34%) and orthopedic surgeons (59%). However, the NATA and AAFP strongly suggest that athletic trainers be a part of the secondary school sports medicine team, with immediate care rendered to the student athlete.4,5
Of note, 58% of the athletic directors responding to the survey stated that they are required to have a licensed medical provider present at football games, and 3% were unsure whether any such guidelines existed. Given the responsibility possessed by athletic directors as the chief athletic administrator within a high school, this reported lack of knowledge is alarming. Although the formal absence of required coverage may exist statewide, the knowledge of existing rules should be minimally held by organizational leaders in an effort to provide optimal care and simultaneously avoid unnecessary litigation.
The existing relationship between each high school and the type of medical coverage also varied. In some cases, schools paid a financial remuneration to the medical provider through a formally preestablished written contract. In other cases, medical providers offered services to the school at no cost, occasionally requesting marketing opportunities in return. Not surprising, in a few cases, athletic directors reported that medical providers actually paid the school for the official rights to be the sole medical provider for the athletics program. The latter practice is one that is currently not accepted within professional sports franchises as a result of considerable unethical possibilities that could arise.16
This survey did not obtain demographic data to include the size of each individual reporting school. Student body population could affect financial resources, ultimately playing a role in the decision making regarding the type of medical provider chosen. Lack of resources at smaller schools is also a major reason for the opposition of mandated types of medical coverage because some schools simply may not be able to afford the minimally suggested services. Previous data reported by Culpepper and Niemann17 identified high schools in Alabama as having different levels of health care availability based on the size of the school and the geographical distance separating the high school from the nearest medical facility.
The results of this survey suggest that in the state of Florida, regardless of the knowledge possessed about sports injury and risk in the sport of football, on-site medical coverage varies and is inconsistent. Based on the results of this survey, in conjunction with previously established available injury pattern data and existing real-time injury surveillance data specific to Florida high school football, minimally appropriate medical coverage guidelines should be developed2 (also K.D.L., B.J.M., J.G.K., et al, unpublished data, 2008). Identifying perceived and real barriers to standardized medical coverage among Florida high schools will serve to educate vested parties and enable progress toward the development of safe practices.
Athletic directors in the state of Florida use a variety of providers to offer on-site medical coverage at high school football games, including no coverage at all. Despite nationwide consistency of injury patterns and risk associated with the sport of football, the FHSAA does not have standardized guidelines for medical coverage associated with high school football games, thus leaving the decision to each school. Although medical coverage in the state of Florida has been found to be inconsistent, of more concern are the 34% of athletic directors who reported no medical coverage at all. Future studies should further examine the effects of inconsistent medical coverage at high school football games and whether any of the existing practices for providing medical coverage pose a greater risk than others to the student athletes.
Implications for Clinical Practice
Medical coverage for high school football games in Florida is inconsistent; of greater concern are the schools that report no medical coverage. It is clear from previously documented injuries and risks associated with the game of football that appropriate medical coverage must be present at all high school games. The FHSAA and appropriate sports medicine organizations should join forces to establish minimally appropriate medical coverage guidelines. Established guidelines should then be mandated at all high school football games.
- Ring LR. Participation numbers rise in 2006–2007. http://www.fhsaa.org/news/2007/0919.htm. Published September 19, 2007. Accessed June 23, 2008.
- Comstock RD, Knox C, Yard E, et al. Sports-related injuries among high school athletes: United States, 2005–2006 school year. JAMA. 2006;296:2673–2674. doi:10.1001/jama.296.22.2673 [CrossRef]
- Almquist J, Valovich McLeod TC, Cavanna A, et al. Summary statement: Appropriate medical care for the secondary school-aged athlete. J Athl Train. 2008:43:416–427. doi:10.4085/1062-6050-43.4.416 [CrossRef]
- National Athletic Trainers’ Association. Secondary school official statement. http://www.nata.org/sites/default/files/SecondarySchool.pdf. Accessed September 3, 2010.
- American Academy of Family Practice. Sports medicine, athletic trainers for high school athletes. 1989, 2007. http://www.aafp.org/online/en/home/policy/policies/s/athletictrainhsathletes.html Accessed September 3, 2010.
- Casa DJ, Pagnotta KD, Pinkus DE, et al. Should coaches be in charge of care for medical emergencies in high school sport?Athletic Training & Sports Health Care. 2009;1:144–146. doi:10.3928/19425864-20090625-01 [CrossRef]
- Nass SJ. A survey of athletic medicine outreach programs in Wisconsin. J Ath Train. 1992;29:180–183.
- Rutherford DS, Niedfeldt MW, Young C. Medical coverage of high school football in Wisconsin in 1997. Clin J Sports Med. 1999;9:209–215. doi:10.1097/00042752-199910000-00005 [CrossRef]
- Knowles SB, Marshall SW, Bowling JM, et al. A prospective study of injury incidence among North Carolina high school athletes. Am J Epidemiol. 2006;164:1209–1221. doi:10.1093/aje/kwj337 [CrossRef]
- Aukerman DF, Aukerman MM, Browning D. Medical coverage of high school athletics in North Carolina. South Med J. 2006;99:132–136. doi:10.1097/01.smj.0000199749.22741.5e [CrossRef]
- Vangsness CT, Hunt TU, Uram M, et al. Survey of health care coverage of high school football in Southern California. Am J Sports Med. 1994;22;719–722. doi:10.1177/036354659402200524 [CrossRef]
- Tonino PM, Bollier MJ. Medical supervision of high school football in Chicago. Phys Sports Med. 2004;32(2):37–40.
- Bell K, Prendergast HM, Schlichting A, et al. Preparedness among Illinois high school athletic departments: Does size or location matter?The Internet Journal of Health. 2005;4(2):n.p.
- Notebaert AJ, Guskiewicz KM. Current trends in athletic training practice for concussion assessment and management. J Athl Train. 2005;40:320–325.
- Hendrix AE, Acevedo EO, Hebert E. An examination of stress and burnout in certified athletic trainers at Division I-A universities. J Athl Train. 2000;35:139–144.
- The American Orthopaedic Society for Sports Medicine. Principles for Selecting Team Medical Coverage. Rosemont, IL: American Orthopaedic Society for Sports Medicine; 2005.
- Culpepper MI, Niemann KM. Professional personnel in health care among secondary school athletics in Alabama. South Med J. 1987;80:336–338. doi:10.1097/00007611-198703000-00015 [CrossRef]