Analysis of the data revealed three overarching themes regarding EMS personnel's perceptions of athletic trainers: (1) EMS protocols determine how EMS personnel respond to and handle situations on the field, (2) EMS personnel possess a lack of knowledge regarding the emergency care domain within athletic training education, and (3) previous experiences with athletic trainers guide overall trust of the profession. Each guiding question had associated survey questions. After data analysis, each guiding question was grouped into a theme.
Theme 1: EMS Protocols Determine How EMS Personnel Respond to and Handle Situations on the Field
Guiding Question 1.What do EMS personnel perceive as their (EMS') role on the field during an emergency situation at an athletic event? Associated survey questions for Guiding Question 1 were: What do you think your roles and responsibilities are on the field in an athletic emergency when an athletic trainer is NOT present? And what do you think your roles and responsibilities are on the field in an athletic emergency when an athletic trainer is present? We also asked what EMS personnel believed the athletic trainer's role to be on the field when EMS is present and not present. These questions were used to gain an understanding of what EMS personnel perceived as their duties on the field with and without an athletic trainer present.
We sought to recognize EMS personnel's personal thoughts to compare training level and perceived training level as it pertains to athletic trainers' duties on the field during an emergency. EMS personnel overwhelmingly stated that once they are called to an emergency they will follow their guiding protocols regardless of other professionals present. Many EMS personnel stated that when they arrive on scene “EMS” is in charge (37 responses, 31.36%). Others responded in terms of “patient care” as their primary concern (28 responses, 23.73%), whereas some stated that what they would do depends on the “injury” (25 responses, 21.19%). One response read: “Once requested we must act accordingly with our protocols. Even if the athletic trainer has a protocol in place, the EMS protocol will override the site's protocol.”
In regard to what the athletic trainer should be doing on the field, when EMS is there respondents answered with key terms including “assist EMS” (34 responses, 28.81%), “work with EMS/provide support” (10 responses, 10.16%), and assist “when needed” (21 responses, 17.80%). Other responses included to provide an “assessment” (17 responses, 14.41%) and “care” (34 responses, 28.81%) for the patient to determine when EMS is necessary. This accounts for 99% of responses in regard to the athletic trainer's role on the field when EMS is present. Six responses included athletic trainers guiding the equipment removal process if needed.
One response regarding this question and the incorporation of equipment removal was: “[athletic trainers should] provide any previous medical history and assist with equipment removal as appropriate. We work together for care and destination of the patient.”
Theme 2: EMS Personnel Possess a Lack of Knowledge Regarding the Emergency Care Domain Within Athletic Training Education
Guiding Question 2.What is EMS personnel's knowledge of athletic training? Many studies3–5 and empirical data suggest that EMS personnel and the general public and other health care professionals lack an understanding of athletic training. We sought to answer and discover EMS personnel's general understanding of the athletic training profession and more specifically their understanding of the athletic trainer's education and training in regard to emergency care. Our associated survey questions regarding this guiding question were as follows: In your own words, what is an athletic trainer? What qualifications do athletic trainers have in regard to emergency response and care? What are the roles and responsibilities of an athletic trainer during an athletic emergency?
We found responses concerning knowledge of athletic training: 50 respondents (43%) accurately described one or more of the domains and 36 respondents (31%) showed a general understanding of the profession. Most responses in these categories included words and phrases such as “care and prevention” (58 responses, 50%), “sports injuries” (27 responses, 23%), “medically trained” (8 responses, 7%), and “trained professionals” (6 responses, 5%). One response (EMT-Paramedic) went as far as saying that athletic trainers serve in an “underappreciated role” in the care of athletes. Thirty-four responses fell into two other categories, including personal trainer/training (17 responses, 15%) and a combination of personal training and athletic training, where they stated “helps athletes” (11 responses, 9%), “conditioning” (6 responses, 5%), “train athletes” (< 1%), “keep athletes fit” (< 1%), and other similar responses.
We discovered a resounding lack of understanding of athletic training in the emergency care domain. Responses included statements regarding athletic trainers having general cardiopulmonary resuscitation certification (41 responses, 35%), “unknown,” “dependent on education and certification,” “unsure,” “minimal,” and “I have no clue,” which accounted for 30 responses. In total, this accounts for 71 respondents (61%). Other responses included where the level of emergency training an athletic trainer possesses is due to the amount of experiences he or she has had with emergency care (5 responses, 4%) and athletic trainers should monitor and care for an athlete until EMS personnel arrive.
Specific responses pertaining to emergency training of athletic trainers included: “I do not know, I would hope that they could recognize a ‘real’ emergency condition and do what is necessary to minimize the situation until qualified EMS personnel arrive on scene,” “Unsure of ‘emergency’ response. I would think extensive knowledge in kinetics,” “This varies by individual. Most programs provide for a basic instruction in emergency response and care but other programs and individuals complete further education in this area,” and “The athletic trainer has very good understanding of the injuries that a patient might have knowing the sport etc. . . . Field stuff training level could be up to a Paramedic level but I have seen some [athletic trainers] that have no emergency training.”
Encouraging responses included: “That of a well-educated first responder. It depends on the injury, musculoskeletal, or sporting equipment based, highly trained. Cardiac, allergic reaction, syncopal episodes, etc and support for EMTs.”
Theme 3: Previous Experiences With Athletic Trainers Guide Overall Trust of the Profession
Guiding Question 3.Do EMS personnel trust an athletic trainer during an emergency situation, including management of a cervical spine injury? We had a variety of associated questions related to this guiding question: Have you had interactions with an athletic trainer? If yes, in what context—please explain. Would you trust an athletic trainer to hold c-spine and facilitate the spine boarding of an athlete? Please explain why or why not.
Overall themes that emerged were the experience or lack of experience with athletic trainers guided the trust level of EMS personnel with regard to the profession and with emergency management on the field. We collected encouraging responses (56 of 113 responses, 50%) in regard to athletic trainer/EMS personnel interactions, but also received troubling information (23 of 113 responses, 20%). A positive response was categorized as any answer stating that EMS personnel would work with the athletic trainer. A negative response was categorized as any answer stating EMS personnel would take charge with little or no assistance from an athletic trainer. Of the responses, 30% (34 of 113 responses) were considered neutral because they did not refer to working with an athletic trainer but rather stated they simply follow state protocols.
When asked “Have you had interactions with an athletic trainer? If yes, in what context—please explain,” some positive responses included:
Several times, most often on the football field and in the field of gymnastics. I have always had positive results. The athletic trainer's I have interacted with have always had the patient's best interest at heart and we had a cooperative effort in patient management.
Yes. In my current setting we provide 9-1-1 services to a small urban community with a State University. We provide EMS standby services to the University at various athletic events. We have developed an integral working relationship with the University's athletic trainer Staff. We have integrated training exercises that are scenario based with High Fidelity Simulation Mannequins that allow us to fine tune the integrated response to an injured athlete. Additionally, we use our SIM lab to look for best practice approaches when an integrated response does not go well.
Troubling responses included:
Yes, in emergency settings on the field or court and it is a constant battle of who's in charge of the patient.
Yes, a few bad interactions have soured what should be a great relationship. I've been on scenes with athletic trainers who have refused to allow us to assess open extremity fractures with bleeding and absent distal pulses, prevented us from treating patients who have suffered traumatic brain injuries/seizing.
More detailed responses included:
YES. High School level and College level. We currently have an athletic trainer working for our local high school. However, this relationship is very strained at this time due to miscommunication regarding roles and responsibilities. We have attempted to meet with the athletic trainer to discuss these issues and our offers have been declined.
Indirectly. Grandson was injured in football practice. All athletic trainer did was call parent and didn't recognize concussion or multiple facial fractures. Left child alone to wait on parent. Never examined pt. Father arrived and took pt to the hospital ER. Was immediately admitted for concussion and facial surgery. P.S. Father was EMT and knew what was wrong while athletic trainer couldn't even examine the boy or recognize his serious condition or stay with him till dad arrived. . . .
Further information related to this guiding question of trust were described by one EMT-Paramedic response, which was detailed and echoed the overall thoughts of the responses:
1. Do no harm, 2. Interact with EMS and not against (ie, have them walk it off or walk to sideline and get help), 3. Have a medical file on the sport participant, 4. Have had pre-incident training/planning with EMS to go over roles/responsibilities, 5. Realize that EMS is bound to written protocols that must be followed and if I don't then I need a very good reason why not, and trying to communicate this over a pt on a scene is not the time to try and figure each other out.
Some EMS personnel reported it is dependent on the injury whether or not EMS personnel take the “lead” or the athletic trainer takes the “lead.” Sixty-six responses included words and phrases such as “assess the needs of the patient” and “assess need for EMS personnel” (21 responses, 20%). Some responses included “injury” (26 responses, 22%) and “arrive” (19 responses, 16%), meaning, the athletic trainer should determine what the injury is, call for EMS personnel when warranted, and give care until EMS personnel arrive. These answers account for 99 participants' answers (87%) and included that athletic trainers should hand over care when EMS personnel arrive, communicate what happened, and assist as needed.
In regard to cervical spine stabilization specifically, many EMS personnel voiced concern that their protocols are changing, which may cause confusion, and many answers echo this similarity:
One of the problems we have had is they do not understand or are up to date on our (EMS emergency protocols/procedures), which constantly change. We are required or have to do things different based on our protocols/medical orders. Older athletic trainer's don't understand that. An example is backboarding. No longer do we backboard every patient like we use to. New protocols have come out in the last year that have us back boarding patients a lot less frequently.
Overall, in this category 69% (77 of 111 responses) of EMS personnel stated that they would allow the athletic trainer to hold a cervical spine injury. Respondents cited a positive response to an athletic trainer holding a cervical spine injury based on working with an athletic trainer prior to an emergency situation or that they simply believed an athletic trainer was capable to hold in-line stabilization. Of the responses, 31% (34 of 111 responses) were negative in regard to allowing an athletic trainer to hold a cervical spine injury. Many respondents cited not practicing with an athletic trainer before an emergency, and their lack of understanding of an athletic trainer's training as being reasons why they did not trust an athletic trainer overall. Others mentioned state protocols would not allow them legally to give an athletic trainer authority to hold the cervical spine injury.
Additionally, when broken down by level of certification, EMT-Paramedics showed the most percentage of positive interaction with athletic trainers at 58%. EMT-Advanced showed 52% of responses had positive interactions with athletic trainers, whereas EMT-Basic showed just 37%. Figure 2 shows the positive, negative, and neutral interactions and perceptions of athletic trainers by EMS personnel.
Theme 3: Emergency medical technicians' (EMT) previous experiences with athletic trainers (ATs). EMT-B = EMT-Basic; EMT-P = EMT-Paramedic