The Secondary School Football Coach's Relationship With the Athletic Trainer and Perspectives on Exertional Heat Stroke

Context:

Prior researchers have examined the first-aid knowledge and decision making among high school coaches, but little is known about their perceived knowledge of exertional heat stroke (EHS) or their relationships with an athletic trainer (AT).

Objective:

To examine secondary school football coaches'' perceived knowledge of EHS and their professional relationship with an AT.

Design:

Qualitative study.

Setting:

Web-based management system.

Patients or Other Participants:

Thirty-eight secondary school head football coaches (37 men, 1 woman) participated in this study. Their average age was 47 ± 10 years old, and they had 12 ± 9 years'' experience as a head football coach.

Data Collection and Analysis:

Participants responded to a series of online questions that were focused on their perceived knowledge of EHS and professional relationships with ATs. Data credibility was established through multiple-analyst triangulation and peer review. We analyzed the data by borrowing from the principles of a general inductive approach.

Results:

Two dominant themes emerged from the data: perceived self-confidence of the secondary school coach and the influence of the AT. The first theme highlighted the perceived confidence, due to basic emergency care training, of the coach regarding management of an emergency situation, despite a lack of knowledge. The second theme illustrated the secondary school coach''s positive professional relationships with ATs regarding patient care and emergency procedures. Of the coaches who participated, 89% (34 out of 38) indicated positive interactions with their ATs.

Conclusions:

These secondary school coaches were unaware of the potential causes of EHS or the symptoms associated with EHS, and they had higher perceived levels of self-confidence in management abilities than indicated by their perceived knowledge level. The secondary school football coaches valued and understood the role of the AT regarding patient and emergency care.Key Words: sudden death in sport, emergency care, heat injuries, coach''s knowledge

Key Points

• Because of the limited knowledge of secondary school head football coaches related to the management and care of exertional heat stroke, state high school athletic associations should require all coaches to undergo continuing education on the recognition and management of emergency situations in sport.
• To ensure the safety of secondary school student–athletes, school administrators are encouraged to employ the services of an athletic trainer.

Sudden death in sport continues to be a concern for the secondary school athlete and athletic trainer (AT), as evident by the number of deaths reported during the fall 2011.¹ Cardiac conditions, exertional sickling, and exertional heat stroke (EHS) were the most commonly reported causes of these sport-related deaths. Data regarding sudden death indicate the most common causes, in order, are cardiac death, traumatic head injuries, EHS, exertional sickling, and hyponatremia.^2,3 Advancements including screening instruments, rule changes, and guidelines for participation and activity modifications have helped to reduce and prevent sudden death in sport.Death from EHS is preventable when proper precautions are taken during training and conditioning. Educating athletes, coaches, and parents on the importance of proper hydration during activity and implementing an appropriate heat-acclimatization period during training are some examples of ways EHS deaths can be prevented.⁴ From July 21 through August 15, 2011, 17 deaths occurred during participation in sport and physical activity. Of those 17, 7 have been either confirmed or speculated to be the result of EHS.¹ There have been 13 deaths from EHS in the past 2 years alone, which is on pace to surpass the number of EHS deaths during the 5-year block from 2005 to 2009, during which 18 EHS deaths were recorded.³ Exertional heat stroke can occur regardless of the time of year but often spikes during the preseason conditioning months, especially July and August.⁵Precautions for minimizing sudden death due to EHS consist of appropriate management and treatment, including but not limited to properly trained medical personnel, such as an AT available onsite. Colleges and universities provide health care services to their athletes in the form of athletic training services; however, most secondary school athletes do not benefit from the same consistent onsite medical care that collegiate athletes receive. Fewer than 45% of high schools in the United States employ an AT,⁶ potentially leaving the care in the hands of the coach, parent, or bystander.Lack of proper medical coverage has played a role in some recent EHS deaths. In August 2010, Tyler Davenport, a junior football player from Arkansas, collapsed during practice after suffering EHS. He later died due to complications resulting from the EHS he suffered. Unfortunately, as has happened with other secondary school-aged athletes who have died from EHS, the coaching staff, despite the onset of symptoms and subsequent collapse, did not cool Tyler immediately. In addition, no AT was present to diagnose and begin immediate treatment before the arrival of emergency personnel (D. J. Casa, unpublished data, 2011). Another case highlighting the role of the coach in preventing sudden death in sport involved Max Gilpin, who, similar to Tyler, died of EHS during football practice. Medical reports state that, on the day of Max''s death, the head football coach had the team run condition drills in full gear without water breaks for 45 minutes. At the time of Max''s EHS, no medical staff was present to monitor practice, diagnose his condition, or implement appropriate treatment. Max''s case was the first in United States history in which a coach was prosecuted in criminal court for his role in a player''s death (D. J. Casa, unpublished data, 2011).Despite the recommendations of the National Athletic Trainers'' Association regarding appropriate medical coverage for the secondary school,⁷ many schools fail to provide medical coverage. In lieu of having an AT employed at every secondary school, some states have opted to implement policies placing care in the hands of the coach,⁸ as is the case in the state of Kentucky. This policy change was influenced by the Max Gilpin case and requires coaches to receive advanced sports medicine training to help minimize the occurrence of sudden death.⁸ Currently, there are no national regulations regarding coaching certifications, and many states have adopted their own regulations regarding requirements for initial certification as well as maintenance of the coaching credential. Some states require that all coaches receive training in cardiopulmonary resuscitation (CPR), use of the automated external defibrillator, and first aid as a means to address emergency care procedures, whereas other states have no mandates regarding basic emergency care training. According to the National Federation of State High Schools,⁹ only 37 states require that coaches obtain basic first-aid training to be eligible to coach. Only 14 of those 37 states require coaches to obtain CPR and automated external defibrillation training in addition to basic first aid.⁹ However, the curriculum in these 37 states often centers on more basic concepts rather than on causes, signs and symptoms, and treatment of emergency situations such as EHS and concussions, for example. Additionally, these sessions are often conducted in 1 day of training, during which a coach is expected to retain and put into practice what would take an AT years to master. This training most likely leaves coaches unprepared to handle an emergency situation because they do not have the proper knowledge or training.^8,9The impetus for this study stemmed from the realization that the secondary school coach plays a significant role in preventing sudden death in sport, especially EHS. Because many secondary schools continue to rely on their coaches to protect the safety of their players, it is important to understand secondary school coaches'' current perceptions of and knowledge related to EHS. Evidence of the reliance on the coach as an emergency care provider and determinant in the student–athlete''s well-being is the number of lawsuits filed against coaches. Within the last 5 years, several coaches have been prosecuted under both criminal and civil law for their negligent roles in failing to follow safety guidelines or take precautions related to preventing sudden death in sport. Many of the cases of sudden death in sport have involved EHS or exertional sickling during conditioning sessions or preseason practices, when an AT may not have been present to provide medical care. This may indicate a limited understanding by the coach regarding the causes of sudden death, signs and symptoms of those conditions, and effective prevention measures. Due to the limited data regarding the knowledge of the secondary school head football coach as it relates to the recognition and prevention of EHS, our goal was to gain coaches'' perspectives on this matter.Athletic trainers and coaches are both integral members of the sports medicine team and, despite different roles and training, must be able to work together to help protect the health and safety of the student–athlete. We also paid particular attention to the coaches'' relationships with ATs. The limited research that exists regarding the professional relationship between the 2 indicates that communication is essential; however, coaches lack a complete understanding of the role and training of the AT.¹⁰ Moreover, the presence of an AT within the secondary school setting appears to provide the secondary school coach with a reason to not maintain skills and knowledge regarding emergency care procedures.^11–17 Therefore, the purpose of this study was to examine secondary school football coaches'' perceived knowledge of EHS as well as the professional relationship that exists between them and ATs.     

《英国非酒精性脂肪性肝炎肝移植指南》导读

非酒精性脂肪性肝炎（non—alcoholicsteatohepatitis,NASH）现已成为肝移植愈来愈重要的基础肝病。鉴于晚期NASH患者常并存多种影响肝移植转归的临床问题,而至今尚无针对NASH患者进行肝移植的评估和治疗指南,为此英国移植学会（British Transplant Society,BTS）邀请相关专家制定了指南,以指导肝移植前后NASH患者的处理。     

Diagnosis and management for urosepsis

Urosepsis is defined as sepsis caused by a urogenital tract infection. Urosepsis in adults comprises approximately 25% of all sepsis cases, and is in most cases due to complicated urinary tract infections. The urinary tract is the infection site of severe sepsis or septic shock in approximately 10–30% of cases. Severe sepsis and septic shock is a critical situation, with a reported mortality rate nowadays still ranging from 30% to 40%. Urosepsis is mainly a result of obstructed uropathy of the upper urinary tract, with ureterolithiasis being the most common cause. The complex pathogenesis of sepsis is initiated when pathogen or damage‐associated molecular patterns recognized by pattern recognition receptors of the host innate immune system generate pro‐inflammatory cytokines. A transition from the innate to the adaptive immune system follows until a T_H2 anti‐inflammatory response takes over, leading to immunosuppression. Treatment of urosepsis comprises four major aspects: (i) early diagnosis; (ii) early goal‐directed therapy including optimal pharmacodynamic exposure to antimicrobials both in the plasma and in the urinary tract; (iii) identification and control of the complicating factor in the urinary tract; and (iv) specific sepsis therapy. Early adequate tissue oxygenation, adequate initial antibiotic therapy, and rapid identification and control of the septic focus in the urinary tract are critical steps in the successful management of a patient with urosepsis, which includes early imaging, and an optimal interdisciplinary approach encompassing emergency unit, urological and intensive‐care medicine specialists.     

Interleukin-3 treatment of rhesus monkeys leads to increased production of histamine-releasing cells that express interleukin-3 receptors at high levels

To understand the hematopoietic and nonhematopoietic responses to interleukin-3 (IL-3), expression of cell-surface IL-3 receptors (IL-3R) was examined on bone marrow (BM) cells and peripheral blood (PB) cells of rhesus monkeys during the course of in vivo IL-3 treatment. Whereas IL-3R expression is low in untreated monkeys, IL-3 administration led to a gradual increase in both low- and high-affinity binding sites for IL-3. This increase reflected the total number of cells expressing IL- 3Rs, as detected by flow cytometry using biotinylated IL-3. Most of these IL-3R+ cells in both BM and PB could be characterized as basophilic granulocytes that contained high levels of histamine. In contrast to the effect on these differentiated cells, IL-3 administration did not significantly alter the low level IL-3R expression on immature, CD34+ cells. Further flow cytometric analysis using biotinylated growth factors showed that the IL-3R+ basophils also expressed receptors for granulocyte-macrophage colony-stimulating factor (GM-CSF), but not for IL-6 or Kit ligand. These findings indicated that the IL-3R+ cells included neither monocytes, which express GM-CSFRs and IL-6Rs abundantly, nor mast cells, which express c- kit. By combining flow cytometric and Scatchard data, it was calculated that the basophils contain as many as 1 to 2 x 10(3) high-affinity IL- 3Rs and 15 to 30 x 10(3) low-affinity sites. The finding that in vivo IL-3 treatment leads to the production of large numbers of cells that express high levels of IL-3R and are capable of producing histamine provides an explanation for the often severe allergic reactions that occur during prolonged IL-3 administration. It also indicates that IL- 3, in addition to its direct effects on hematopoietic cells, may also stimulate hematopoiesis through the release of secondary mediators such as histamine by IL-3-responsive mature cells.