1. Injury Care and the Athletic Trainer

2. Sports Medicine vs. Athletic Training
Sports medicine and athletic training are not synonymous.
Sports medicine
--branch of health care encompassing several disciplines
--applies medical and scientific knowledge to prevent and care for injuries or illnesses related to sport, exercise, or recreational activity, and, in doing so, enhances the health fitness and performance of the participant
Athletic training
--medical profession involved in the prevention, assessment, treatment, and rehabilitation of injuries to athletes and other who are engaged in everyday physical activities
--recognized by AMA as an allied health care profession since 1990
--professional association – National Athletic Trainers’ Association (NATA)

3. Sports Medicine
Broad and complex branch of health care encompassing several disciplines.
Essentially it is an area of health care and special services that applies medical and scientific knowledge to prevent, recognize, assess, manage, and rehabilitate injuries or illnesses related to sport, exercise, or recreational activity.
Professionals from several disciplines play key roles in addressing health care for physically active individuals
Broad and complex branch of health care encompassing several disciplines.
Essentially it is an area of health care and special services that applies medical and scientific knowledge to prevent, recognize, assess, manage, and rehabilitate injuries or illnesses related to sport, exercise, or recreational activity.
Professionals from several disciplines play key roles in addressing health care for physically active individuals

4. Athletic Training
Athletic trainers are uniquely qualified to provide health care services to athletes and physically active individuals.
ATCs can expand their medical expertise to include work in clinics, offices, and industrial/occupational settings.
NATA – National Athletic Trainers Association
Establishes standards for professionalism, education, research, and practice settings.
Has played a critical role in the evolution of the skills and qualifications of the ATC.

5. 6 Domains of Athletic Training
Prevention
Clinical Evaluation and Diagnosis
Immediate Care
Treatment, Rehabilitation, and Reconditioning
Organization and Administration
Professional Responsibility

6. Prevention Strategies used to minimize risk.
Pre-participation physical exams
Regular safety checks of equipment, facilities, and field areas
Designing and implementing year round conditioning programs to develop and maintain strength, flexibility, agility, and endurance
Promoting proper lifting techniques and safety in the weight room
Following universal safety precautions to prevent the spread of infectious diseases
Applying appropriate taping, wrappings, protective devices, or braces
Monitoring environmental conditions

7. Clinical Evaluation and Diagnosis
Addresses the responsibilities of the ATC in using standardized clinical practices to make decisions regarding the nature and severity of an injury or illness.
Evaluation
On-field
Off-field
Follow-up
Must follow a systematic format that includes HOPS or SOAP
History, Observation, Palpation, Special Tests
Subjective, Objective, Assesment, Plan

8. Immediate Care
ATC must determine the nature and extent of an injury or illness
Could range from the implementation of emergency care for a life-threatening condition to rendering standard immediate care for a musculoskeletal injury

9. Treatment, Rehabilitation, and Reconditioning
ATC is responsible for the implementation of treatment, rehabilitation, and reconditioning programs appropriate to the diagnosis made during the evaluation and assessment phase.
In consultation with physician, ATC develops a comprehensive treatment program, including therapeutic goals and objectives, selection of appropriate therapeutic modalities and exercise, use of pharmacologic agents, methods to assess and document progress, and criteria for return to participation.

10. Organization and Administration
Developing and executing a series of plans, policies, and procedures to ensure responsive and efficient operation of your program.
Documentation and maintenance of health care records
Services rendered to an injured party
Confidentiality of medical records
Financial, facility, and personnel management
Purchasing of equipment and supplies
Equipment reconditioning
Compliance with defined safety standards
Emergency care protocols
Public relations
Normal operating procedures

11. Professional Responsibility
Expectations of the ATC to adhere to ethical, legal, and other professional standards.
Also includes continuing education requirements

12. ATC Credential Requirements
Graduate from a CAATE-accredited* athletic training education program
Pass the National Certification Exam
Continuing Competence
CEUs
Certification in First Aid
Certification in Emergency Cardiac Care
*CAATE – Commission on Accreditation of Athletic Training Education

13. Work Settings High school and collegiate settings
Professional sports teams
Sports medicine clinics
Industrial/occupational settings
Physician practices
ATCs are generally employed in secondary school, intercollegiate, or professional athletic programs; sports medicine clinics; clinical and industrial health care programs; health and fitness clubs; or a combination of any of the above.
Refer students to NATA website. 13

14. Team Approach Team Physician PCP Coach Athlete PT
CSCS PT
Exercise Physiologist
Nutritionist
Biomechanist

15. Legal Considerations
Practice of athletic training normally tried under tort law
Tort
Omission
Commission
Standard of care vs. scope of care
Standard of Care - Measured by what another minimally competent individual educated and practicing in that profession would have done in the same or similar circumstance to protect an individual from harm or further harm
Scope of care - outlines the role and responsibilities of an individual in that profession
Clearance for participation
Final authority is supervising team physician, not ATC
-- Injury problem has grown to such proportions that it is firmly entrenched in most American court rooms; lawsuits are increasing in frequency and damages awarded relative to injury sustained in sport and physical activity
-- People involved in the delivery of health care are accountable fort their actions
Tort – civil wrong done to an individual whereby the injured party seeks a remedy for damages suffered
Act of omission – an individual fails to perform a legal duty -- example: failure to warn athletes of the potential risks associated with participation; failure to assess a reported injury
Act of commission – an individual commits an act that is not theirs to perform or commits an act that is their duty to perform but carries out the wrong procedure, leading to injury or harm -- example: distributing prescription medication; failing to follow a physicians orders
-- actions are measured against a standard of care provided by individuals who have a direct duty to provide care
Standard of care
-- measured by what another minimally competent individual educated and practicing in that profession would have done in the same or similar circumstance to protect an individual from harm or further harm
-- dictated by the profession's duty or scope of care
-- an individual acting as an athletic trainer will be held to the standard of care expected of an individual holding the ATC credential -- an individual acting as a physician will be held to the standard of care expected of an individual holding a medical license as a physician
Scope of care
--outlines the role and responsibilities of an individual in that profession
RDS – BOC
-- delineates what should be learned in the professional preparation of that individual
Athletic Training Educational Competencies – define the educational domains used in preparing entry-level athletic trainers; each domain is then further defined by a set of cognitive, psychomotor, and affective competencies
risk management
assessment and evaluation
acute care general medical conditions and disabilities pathology of injury and illness pharmacologic aspects of injury and illness nutritional aspects of injury and illness
therapeutic exercise therapeutic modalities
health care administration professional development and responsibilities
psychosocial intervention and referral
-- clearance for participation
-- final authority in determining participation status is the supervising physician, not the ATC

16. Legal Considerations (cont.)
Negligence
Failure to provide a duty of care
Negligent torts can result from
Malfeasance – Commit an act that is not their responsibility
Misfeasance – Your responsibility, but wrong procedure
Nonfeasance – Failure to perform Legal Duty
Malpractice – Commits negligent act while providing care
Gross negligence – Total disregard for safety of others
Criteria required to prove negligence
Negligence
-- failure to carry out a legal duty
-- participants assume some inherent risk, but do not assume the risk that the professional will breach their duty of care
-- negligent tort may occur as a result of:
Malfeasance
-- occurs when an individual commits an act that is not their responsibility to perform
-- example: if you suspect a neck injury and remove the football helmet, you could be liable
Misfeasance
-- occurs when an individual commits an act that is their responsibility to perform but uses the wrong procedure or does the right procedure in an improper manner.
-- example: if you suspect a neck injury and improperly secure the head and neck region to the rigid spine board, you could be held liable
Nonfeasance
-- occurs when an individual fails to perform their legal duty of care
-- example: if you suspect, or should have suspected, a neck injury and failed to use a rigid back board to stabilize the individual, you could be held liable
Malpractice
-- occurs when an individual commits a negligent act while providing care
Gross negligence
-- occurs when an individual has total disregard for the safety of others
Criteria to find an individual liable: the injured person must prove that:
there was a duty of care
there was a breach of that duty
there was harm (e.g., pain and suffering, permanent disability, or loss of wages), and
the resulting harm was a direct cause from that breach of duty

17. Legal Liabilities Failure to Warn Foreseeability of Harm
Participants must be informed that risk for injury exists and understand the nature of that risk
Foreseeability of Harm
Recognizing a potential danger and removing the danger before an injury occurs
Athletic trainers (and coaches) should be proactive and take steps to limit the risk of litigation.
Failure to warn
-- inform potential sport participants of the risks for injury during sport participation
-- participants and parents of minor children should learn that risk for injury exists and must understand the nature of that risk so informed judgments may be made about participation
-- comprehending the nature of the risk is determined by the participant's age, experience, and knowledge of pertinent information about the risk
-- variety of methods: preseason meetings; post warning signs; require protective equipment
Foreseeability of harm
--exists when danger is apparent, or should have been apparent, resulting in an unreasonably unsafe condition
-- can be identified during regular inspections of gymnasiums, field areas, swimming pools, safety equipment, and athletic training facilities
-- examples: unpadded walls under the basketball hoops, slippery floors near a whirlpool, failure to follow universal safety precautions
-- unsafe conditions should be identified and reported 17

18. Legal Liabilities (cont.)
Informed Consent
Injured party has been reasonably informed of needed treatment, possible alternative treatment, and advantages and disadvantages of each course of action
Exclusionary clause – identify conditions not treated by the ATC
Obtain prior to any treatment
Potential for battery
Informed consent
-- implies that an injured party has been reasonably informed of needed treatment, possible alternative treatment, and advantages and disadvantages of each course of action
-- valid consent can only be obtained from one who is competent to grant it – parent or over 18 years old
-- authorization to treat in the absence of the parent, or in the event the individual is physically unable to consent to treatment, should be obtained in writing prior to the beginning of sport participation
-- exclusionary clause – identifies conditions that will not be treated by the athletic trainer (e.g., injuries not associated with direct participation in sport)
-- must be sensitive to cultural and religious beliefs and practices and honor those practices by providing appropriate care consistent with the wishes of the athlete; example: in some cultures, a woman may be taught not to undress or bare skin in the presence of a man other than her husband; in this case, it would necessary to refer the athlete to a female athletic trainer
Battery
-- any unpermitted or intentional contact with another individual without their consent 18

19. Legal Liabilities (cont.)
Refusing help
Individuals have the right to refuse treatment
Exception: increased risk for further injury
Product liability
Implied warranty
Expressed warranty
Strict liability
NOCSAE
Confidentiality
Right to privacy
Refusing help
-- regardless of the reason given to refuse help, the conscious and medically competent individual has the right to refuse treatment
-- exemption may occur when failure to move the injured party may result in an increased risk for further injury to the injured party or to others in the vicinity of the accident; example: during an organized bike race, several bikers collide and fall on a busy road; it would be appropriate to move any injured individuals off the road so as not to endanger themselves or any approaching motorists
Product liability
Implied warranty
-- manufacturers have a duty of care to design, manufacture, and package safe equipment that will not cause injury to an individual when the equipment is used as it was intended
Expressed warranty
-- written guarantee that the product is safe for use
-- in football, there is an implied warranty that if fitted and used properly, the helmet can protect the head and brain from certain injuries
Strict liability
-- the manufacturer is liable for any and all defective or hazardous equipment that unduly threatens an individual's personal safety
National Operating Committee on Standards for Athletic Equipment (NOCSAE)
-- establishes minimum standards for football helmets
-- any alteration or modification to any protective equipment may negate the manufacturer’s liability
Confidentiality
-- release of any medical information must be acknowledged in writing by the sport participant (or if under 18 years of age, their parent); if permission is given to release information, it should identify what information can be shared with an individual other than the patient’s physician
-- information provided to coaches and parents should be on a need to know basis only and given with the full knowledge and consent of the athlete, supervising physician, and athletic trainer
-- confidentiality should also extend to all medical records kept within the confines of the athletic training room 19

20. Legal Defenses Assumption of risk
Individual acknowledges understanding of the risks of their participation in the activity and voluntarily chooses to participate, assuming all risks of injury or even death due to their participation
If the threat of litigation exists, many athletic trainers rely upon certain conditions to strengthen their case.
Assumption of risk
-- require athletes to sign an assumption of risk form; this is not the same as a permission slip
-- by signing the form, the athlete acknowledges:
the material risks and appreciates, knowingly, and reasonably anticipating that other injuries and even death are possibilities
voluntarily participation in the activity and assumes all risks of injury or even death due to their participation
-- assumption of risk form does not assume the risk that the professional will breach their duty of care 20

21. Legal Defenses (cont.) Good Samaritan laws Comparative negligence
Conditions vary from state to state, but immunity generally applies only when emergency first aider:
Acts during an emergency
Acts in good faith
Acts without expected compensation
Is not guilty of misconduct or gross negligence
Comparative negligence
Relative degree of negligence
Damages awarded on a proportionate basis
Good Samaritan laws
-- the laws vary from state to state
-- immunity generally applies only when the emergency first aider:
acts during an emergency
acts in good faith to help the victim
acts without expected compensation
is not guilty of any malicious misconduct or gross negligence toward the injured party
-- laws are easy to get around and should not be relied upon by rescuers who erroneously believe the laws will protect them from litigation regardless of their actions
Comparative negligence
-- refers to the relative degree of negligence on the part of the plaintiff and defendant, with damages awarded on a basis proportionate to each person’s carelessness
-- example: if the athlete was found to be 30% at fault for their own injury (contributory negligent) and the defendant 70% at fault, then on a $100,000 judgment, the defendant would be responsible for $70,000 in damages and the athlete (plaintiff) would assume an equivalent of $30,000 in damages 21

22. Preventing Litigation
Understand and complete duty of care
Steps to reduce risk of litigation
Know NATA position and consensus statements
All members of the health delivery team should be aware of their duty of care consistent with current state law and complete that duty of care within established policies and standards of practice.
Strategies for reducing the risk of litigation
-- ensure that all personnel are properly licensed for practicing within the laws of the state, particularly in providing athletic training services
-- be familiar with the NATA position and consensus statements
-- hire qualified coaches, athletic trainers, and fitness instructors and establish strict rules for supervision and use of the facility
-- have an established preparticipation plan including:
annual preparticipation health examination
insurance verification
medical data information cards
physician’s clearance to participate
-- hold a preseason/preparticipation meeting to:
inform participants and parents of the risks involved in sport participation
obtain written informed consent from the parents of minor children before participation
document what was said at the preseason or preparticipation meeting
-- have a well-established primary health care delivery team to:
develop a total health care plan including staff responsibilities during emergency situations
obtain adequate secondary health insurance for participants and liability insurance for the staff
-- establish a communication system at each field or gymnasium station
-- maintain appropriate standard injury documentation and referral forms
-- develop criteria to return an injured player to participation
-- select and purchase quality safety equipment from a reputable dealer
-- inspect safety equipment and supervise proper fitting, adjustment, and repair of equipment
-- inspect equipment, facilities, and fields for hazards and prohibit their use if found to be dangerous
-- establish policies for documentation, confidentiality, and storage of medical records
-- keep accurate records of equipment purchases, reconditioning, and repairs
-- post warning signs in plain sight on and around equipment to inform of the risks involved in abuse of equipment and to describe proper use of the equipment
-- post visible signs in the swimming pool area giving the depth of the pool and prohibiting diving in the shallow area
-- post warning signs in the whirlpool area to inform individuals not to touch the turbine device while standing or sitting in water
-- require participants to wear protective equipment regularly, including protective eyewear in appropriate racquet sports
-- issue only those helmets that meet standards established by the National Operating Commission on Standards for Athletic Equipment (NOCSAE); inform players that a helmet cannot prevent all injuries, and the possibility exists that serious head and neck injuries may occur in the sport
-- provide continuing education for coaches and athletic trainers through in-service workshops and programs
-- act as a reasonably prudent professional in caring for all sport participants 22