Contents for chiropractors' athletic event emergency bags☆

Article Outline

• Abstract
• Introduction
• Methods
  • Preliminary preparation
  • Data sources and study selection
  • Data extraction
  • Expert review
  • Data synthesis
• Results
• Discussion
  • Study interpretations
  • Study limitations
• Conclusion
• Acknowledgements
• References
• Copyright

Abstract 

Background: Chiropractors are providing health care at a growing number of athletic events. With this increased participation it is critical that chiropractors be adequately prepared for these events with the proper knowledge, skill, and equipment to provide emergency care. Objective: The objective was to recommend an inventory of items that should be included in a chiropractor's event-site emergency bag, based on the best available evidence. Data Sources: A pilot search was conducted by searching MEDLINE to retrieve articles regarding emergency supplies used at athletic events. Key terms were then taken from the pilot search and used to conduct a systematic search and review of the literature. Study Selection: Articles were included if they were published in English and discussed athletic event-site emergency first aid and supplies. Articles published in non–peer-reviewed publications were excluded. Data Extraction: Items recommended for event-site emergency care bags were extracted from 19 studies and reviewed by an expert panel of sports chiropractors. Expert rankings from a Likert scale were then averaged for each item. Data Synthesis: Items are categorized as recommended, possibly recommended, or not recommended based on expert rankings and frequency counts of citations. Results: The most recommended items were latex gloves, penlights, and oral airways. An inventory of 169 items with citations and ratings is included in this review. Conclusion: This is the first evidence-based article to delineate appropriate first aid and emergency equipment for sports chiropractors. This article has utility for educators who teach emergency care for athletic events and for practitioners who would like to have a clear inventory for their emergency bags. (J Manipulative Physiol Ther 2002;25:e9)

Keywords:  Athletic Injuries, Chiropractic, Equipment and Supplies, First Aid, Sideline, Sports Medicine

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Introduction 

In the United States, chiropractors are increasingly being placed in roles as team doctors and donating their time and services for community-oriented athletic events such as fun runs and football games. Chiropractors are fulfilling these roles for a variety of reasons. One motivation is that the need for basic emergency care and first aid at athletic events is compelling and has prompted numerous health care disciplines to begin contributing to this area of need.¹ Athletic events have an alarmingly low rate of coverage as it relates to health care; this is particularly true of high school athletics and is even worse in rural areas. In many situations untrained personnel treat athletic injuries because there is a lack of on-field health-care providers.² One study reports that between 27% and 82% of high schools do not have a physician present during football games and lack basic emergency equipment and that 40% or less of the coaches are trained in cardiopulmonary resuscitation.³ Results of another study demonstrate that 5% of high schools in South Carolina have a chiropractor on site for scheduled home football games.²

Beyond the high school level of competition, chiropractors are being added to the health care team or are the sole health care provider for professional teams and elite international events. For example, chiropractors are involved in managing the health of those in the Olympics,⁴, ⁵ professional triathlon,⁶ cycling,⁷ and hockey,⁸ as well as other sports.

Another motivation for the increase in chiropractors' involvement in sport events is that thousands of chiropractors are receiving advanced post-graduate training in managing sports injuries. According to the American Chiropractic Board of Sports Physicians (correspondence with Jenny Quastad, American Chiropractic Board of Sports Physicians (ACBSP) secretary, May 21, 2001), there are currently 3425 certified chiropractic sports physicians and 162 diplomates of the ACBSP (DACBSP). These doctors are trained to care for athletes at events, with the diplomate training providing the highest level of sports injury education in chiropractic.⁹

In addition to doctors who have completed these advanced training programs, chiropractors who have advanced training in other fields such as orthopedics or rehabilitation, and chiropractors without special training also provide care at events. It is difficult to estimate the number of chiropractors providing care at athletic events, but if one used only the data from the ACBSP, it represents approximately 3500 United States chiropractors, or approximately 7% of the chiropractors in the United States, and this is an underestimate.

The increase of chiropractors staffing athletic events is accompanied by a higher incidence of exposure to emergency situations and a greater level of accountability on behalf of the doctor of chiropractic. For example, cuts are the most frequent cause of non-fatal injuries in people 10 to 17 years of age, leading to an incidence of more than 59 cuts per 1000 injuries.¹⁰ Therefore it would seem that sports chiropractors should be equipped with the proper knowledge of wound care and the supplies needed to provide it.

Two articles in the chiropractic literature discuss the role of the chiropractor at events and mention some emergency supplies that should be available.¹⁰, ¹¹ Several articles are published discussing what emergency equipment medical professionals should bring to events. However, no peer-reviewed articles in the chiropractic literature focus specifically on what a chiropractor, who has a different scope of practice than other health care providers, should bring for emergency care. Therefore there exists a clear need for a reliable list of contents for an emergency kit to be used by chiropractors at athletic events. The purpose of this article is to create such a list.

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Methods 

Preliminary preparation 

A pilot search was conducted in October of 1999 to survey the literature for articles outlining the recommended contents for an event-site emergency bag. MEDLINE was searched with the keywords “trauma kit,” “sideline,” and “first aid” for articles published in English from 1966 through October 1999. Very few articles were available from this search. These articles were obtained and reviewed for relevance and for additional keywords. In fact, only 2 articles listed specific items for inclusion in an emergency kit. Based on key words found in the pilot articles, search terms were selected and used to conduct the main literature search for this study.

Data sources and study selection 

For the main literature search, we used terms recognized by the search vocabulary of the individual databases searched. MEDLINE, the Index to the Chiropractic Literature, and the Cumulative Index to Nursing and Allied Health Literature were searched with the strategies outlined in Table 1.

Table 1. Search strategies used for this article

The Cumulative Index to Nursing and Allied Health Literature and the Index to the Chiropractic Literature were searched with both individual terms and search strings. Because the individual search terms for MEDLINE are very general and result in a very large number of returned studies, only search strings were used.

Articles were included in this review if they were published in English and discussed athletic event-site emergency first aid and supplies. Any article obtained not pertaining to emergency supplies was excluded from this review. Only sport events were considered in this review; articles regarding summer camps, office first aid systems, and other such programs were excluded because they did not fit the context of this article. Articles not published in peer-reviewed journals such as trade magazines were not included. We independently verified which articles retrieved should be included or excluded from the study based on the predetermined criteria. For any study on which we disagreed, discussion about the article's properties was had until consensus was obtained.

Data extraction 

The primary author reviewed each article for items recommended for inclusion in an event-site emergency bag and entered the citation for each study into a data extraction table with Microsoft Excel 97 (Redmond, Wash). Full article citations were listed alphabetically by lead author horizontally along the top of the spreadsheet, and the items recommended in each study were listed alphabetically in a vertical orientation along the left-hand column. Items too large to fit into an emergency bag such as bolt cutters and spineboards or elements not within the scope of chiropractic (eg, laryngoscope, intravenous anesthetic, epinephrine) are not included in the evidence tables. In an effort to concentrate specifically on emergency equipment, non-emergency items (eg, adjusting table) that chiropractors also bring to these events are not discussed.

The raw database was then printed and reviewed by us. Because items had been entered into the spreadsheet verbatim from the articles reviewed, there was repetition of similar items. Items listed by a brand name or items listed under generic terms were then consolidated into common generic categories, creating a condensed data extraction table. For example, Ace wraps, Ace bandages, elastic wraps, and elastic bandages were collapsed into a general category of “elastic bandages.”

Expert review 

Evidence-based practice, as defined by Muir Gray, emphasizes the judicious integration of scientific research with clinical experience.¹² In an effort to enhance the application of the findings of this research to the practice of sports chiropractic, we recruited 8 experts in the field of sports chiropractic to critically evaluate the items extracted from the literature review. Five reviewers had the following qualifications: a minimum of 5 years of event-site experience at elite and local level athletic events, experience teaching about sports injuries in a post-graduate setting, achievement of the certification of diplomate from the ACBSP, and at least 1 rotation of training at 1 of the United States Olympic Training Centers.

Of the remaining 3 reviewers, 2 chiropractors were not trained at the U.S. Olympic Training Center but have served as event doctors for multiple elite international competitions for 5 years or more, teach postgraduate courses in sports courses, possess diplomate certifications from the ACBSP, and are recognized experts in the field. The final reviewer has served a rotation of training at the U.S. Olympic Training Center, attained diplomate certifications in the fields of orthopedics and rehabilitation, is a certified chiropractic sports physician, and teaches extensively in addition to serving as a team doctor for amateur and professional teams.

The experts evaluated the list of items for relevance to chiropractors providing event-site care based on their experience. They were instructed to rate each item on a Likert scale from 0 to 4, as shown in Table 2.

Table 2. Definitions of ratings given to the experts

The reviewers were also asked to comment on any item if they felt it was necessary or to add an item to the list if they felt it belonged in an event-site emergency bag. If a reviewer did not rate an item on the Likert scale, he or she was contacted via telephone to obtain a rating.

Data synthesis 

After data entry, all rows were summed to determine the total number of studies recommending each item. The mean expert rating for each item was calculated and entered next to the literature frequency count on the spreadsheet. The spreadsheet was then reorganized in decreasing order with items most recommended by the expert reviewers on top to items least recommended on the bottom.

The spreadsheet was divided into the categories of “recommended,” “possibly recommended,” and “not recommended.” Items in the “recommended” category received a mean rating between 3 and 4 from the experts. These are items that appear important to include in the event-site emergency bag of a sports chiropractor regardless of the event attended. Items in the “possibly recommended” category received a mean rating from the review panel between 1.0 and 3.0. These are items that may be required for inclusion in an event-site emergency bag depending on the event or did not receive strong consensus from the experts as being important. Items in the “not recommended” category received a mean rating from the review panel less than or equal to 1.0. Items in this category are not commonly used items by chiropractors and probably should not be included into the event-site emergency bag unless a doctor finds a frequent need for the item.

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Results 

A total of 55 articles from the main search were retrieved from libraries. Forty-six articles were retrieved from the literature searches (Table 3).

Table 3. Results of literature search

Nine additional articles were found as citations in the bodies of the previously described 46 articles. After the 55 retrieved articles were reviewed and evaluated, 19 were included in the final literature review.1, 3, 9, 10, 11, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26

Five hundred forty-seven emergency items were extracted as raw data. With the methods previously described, the raw data were consolidated to a list of 169 items, which was submitted to the expert panel. Seven of the 8 expert reviewers returned their ratings; 61 of these items are in the most recommended category, 96 in the possibly recommended category, and 12 are not recommended. Tables 4, 5, and 6 list the items, frequency counts, and expert ratings.

Table 4. Recommended items for emergency kit

N, Needed item; R, restocked item.

Table 5. Items possibly recommended for emergency kit

N, Needed item; R, restocked item.

Table 6. Items not recommended for emergency kit

N, Needed item; R, restocked item.

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Discussion 

Study interpretations 

The bag used to carry emergency supplies is a good place to start a discussion. The bag should be large enough to contain the necessary equipment but should not be too large to transport.¹⁵, ²⁴ Hard-shelled bags have the advantage of being durable but may be difficult to transport. Soft bags are easier to transport but lack durability.¹⁵ Regardless of the construction of the outside of the bag, the compartments of the bag should be labeled for easy item retrieval. Internal compartments should be divided to ensure organization.¹⁵, ²⁴, ²⁶ We also recommend that the bag, particularly the bottom, be waterproof to protect the items inside and that the owner's name should be prominently marked on the outside of the bag and all non-disposable equipment inside. The Figure shows hard- and soft-shelled bags with the items that received a rating of “recommended” from the expert reviewers.

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• Fig. Hard-shelled (left) and soft-shelled (right) emergency bags shown with items that are recommended for inclusion in a chiropractor's athletic event emergency bag.

One could assume that the relative importance of emergency kit items could be derived from the number of authors who write about them. We did not think that this would be a safe assumption to make because the anecdotal methods of the articles reviewed posed a problem that items were only mentioned based on the opinion of the author. Therefore we felt that it would be best to report the results not only in groups of frequency counts but also by the recommendations of the expert reviewers. The reviewers' opinions also placed a focus on what was important for chiropractors to bring to events, something that has not been published before. For example, although suture kits were recommended in 8 of the articles reviewed,¹, ³, ¹¹, ¹⁵, ¹⁷, ¹⁸, ²⁰, ²⁴ they are not recommended by the expert reviewers because of scope of practice issues and clinical preference. However, we did notice that there seems to be a trend in the results where the items written about most frequently also received higher ratings from the reviewers. It should be noted that the reviewers were blinded to the frequency of citations when they rated the items.

Once a chiropractor has the bag itself and knows the important contents for it, the items must be acquired. Table 4, Table 5, Table 6 can be used as an inventory check sheet for doctors when establishing or restocking an event-site emergency bag. There is 1 column that can be checked if an item is needed and another that may be marked when the item has been restocked. This table may be useful for doctors who have their office staff order equipment because it only requires that the doctor identify what is needed, and he or she also receives feedback on what was actually purchased. If this inventory list is kept in the bag, the “needed” box can be marked for items that are depleted during an event, thus saving the doctor time. The inventory list can also be laminated, needed items marked with a grease pencil, and cleaned and re-used at multiple events.

Although pre-packaged first aid and emergency bags are available for purchase, they may be stocked for general first aid and therefore may not be acceptable for athletic use. In addition, some of the items stocked in an emergency bag may be perishable and will expire if not used by the indicated date. It is the responsibility of the individual maintaining the inventory of the emergency bag to periodically check the expiration dates of items²⁴ and replace all items that have expired. Two reviewers specifically noted that it is also the duty of the team doctor to know which items in the kit may contain substances banned in athletic competition. One example may be that decongestants often contain ephedrine, a commonly banned substance.

Study limitations 

The chiropractic scope of practice varies from state to state based on the regulations set by the individual state boards and statutes. Because of this variance, some of the items recommended in the final data may not be within the scope of practice of some sports chiropractors. We chose to include all items, relying on the responsibility of the chiropractors to know the scope of practice in the state(s) where they provide sports care.

The consolidation of named and generic items into generic categories may introduce unintended sources of error into this study. For example, we consolidated Ace wraps, Ace bandages, elastic wraps, and elastic bandages into a general category of “elastic bandages.” This is a potential limitation, because practitioners may feel that specific brands or sizes may be preferential to a generically named or sized item.

MEDLINE was not searched with individual search terms. With the use of the pilot search, we determined this type of search would not provide us with the specific information required for completion of our study. In addition, searching MEDLINE with our individual search terms generated very large lists of citations that were impossible to review and included numerous irrelevant hits. Therefore MEDLINE terms were combined into search strings.

For this project we searched MEDLINE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Index to the Chiropractic Literature (ICL), because these are commonly searched databases and were the databases available to us. At the time of this study, the Allied and Complementary Medicine Database and the Manual, Alternative, and Natural Therapy Index System (MANTIS) were not available to us; however, they may have revealed useful results as they are related to the practice of sports chiropractic. Future studies in this area should therefore include searches of these databases. In addition, it was recommended that the Cochrane Library of Systematic Reviews be searched. However, this database of systematic reviews reports results of meta-analyses for interventions, rather than descriptive reports, such as the topic of this article. Therefore it was not used.

The weight of evidence that should be afforded to this article is limited by the study designs reviewed. Originally we also had intended on including the sophistication and quality of the research design used for each article we reviewed as a third multiplying factor. However, because all final 19 studies were anecdotal reports, the multiplying factor would be a constant and would not add any value to the data synthesis.

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Conclusion 

Emergency bags brought by chiropractors to athletic events should contain the appropriate equipment to provide first aid and emergency care to athletes. Based on available literature and expert opinion, 61 recommended, 96 possibly recommended, and 12 not recommended items are presented. The bag itself should be organized, durable, and easy to transport. The results of this study may also serve as an inventory checklist for building or restocking event-site emergency bags.

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Acknowledgements 

We thank Drs Joel P. Carmichael, Carl H. Heigl, Steven C. Hickey, Abigail A. Irwin, Michael Reed, John Scaringe, and Blase J. Toto for participating as expert reviewers in our study.

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