Management Strategies for the Health and Well Being of the CMS Intercollegiate Student-Athlete

• Mission Statement
• Professional Standards
• Program Authority and Facility Operations
• Medical Screenings, Records, Insurance, and Emergencies
• Catastrophic Incident Management
• Blood Borne Pathogens and Infectious Diseases
• Dehydration, Heat-and-Cold Related Illness
• Lightning/Air Quality Considerations
• Type I Diabetes
• Asthma
• Concussion Management
• Eating Disorders
• Management Strategies Regarding Rhabdomyolysis
• Management Strategies for Mental Health
• Physician Agreement

Mission Statement

CMS Sports Medicine is committed to providing outstanding health care to the intercollegiate student-athletes of Claremont McKenna, Harvey Mudd and Scripps Colleges. Through the application of our professional knowledge and collective experience, the Sports Medicine Staff will strive to maintain and improve the level of excellence achieved by our student athletes. Care for these individuals, including education, prevention, evaluation, treatment, and rehabilitation will be carried out in a positive atmosphere where diversity and individual needs are recognized and appreciated. The Sports Medicine Staff, in collaboration with our Team Physicians, the Student Health Center, and other area health professionals, endeavor to provide proper direction in all areas of physical and mental well-being.

Professional Standards

NATA Code of Ethics

Preamble

The National Athletic Trainers’ Association Code of Ethics states the principles of ethical behavior that should be followed in the practice of athletic training.  It is intended to establish and maintain high standards and professionalism for the athletic training profession.
 
The principles do not cover every situation encountered by the practicing athletic trainer, but are representative of the spirit with which athletic trainers should make decisions.  The principles are written generally; the circumstances of a situation will determine the interpretation and application of a given principle and of the Code as a whole.  When a conflict exists between the Code and the law, the law prevails.
 

Principle 1: Members Shall Practice with Compassion, Respecting the Rights, Well-being, and Dignity of Others 

1.  Members shall render quality patient care regardless of the patient’s race, religion, age, sex, ethnic or national origin, disability, health status, socioeconomic status, sexual orientation, or gender identity.
2. Member’s duty to the patient is the first concern, and therefore members are obligated to place the well-being and long-term well-being of their patient above other groups and their own self-interest, to provide competent care in all decisions, and advocate for the best medical interest and safety of their patient at all times as delineated by professional statements and best practices.
3. Members shall preserve the confidentiality of privileged information and shall not release or otherwise publish in any form, including social media, such information to a third party not involved in the patient’s care without a release unless required by law.

Principle 2: Members Shall Comply With the Laws and Regulations Governing the Practice of Athletic Training, National Athletic Trainers’ Association (NATA) Membership Standards, and the NATA Code of Ethic

1. Members shall comply with applicable local, state, federal laws, and any state athletic training practice acts.
2. Members shall understand and uphold all NATA Standards and the Code of Ethics.
3. Members shall refrain from, and report illegal or unethical practices related to athletic training. Updated and BOD Approved March 2018
4. Members shall cooperate in ethics investigations by the NATA, state professional licensing/regulatory boards, or other professional agencies governing the athletic training profession. Failure to fully cooperate in an ethics investigation is an ethical violation.
5. Members must not file, or encourage others to file, a frivolous ethics complaint with any organization or entity governing the athletic training profession such that the complaint is unfounded or willfully ignore facts that would disprove the allegation(s) in the complaint.
6. Members shall refrain from substance and alcohol abuse.  For any member involved in an ethics proceeding with NATA and who, as part of that proceeding is seeking rehabilitation for substance or alcohol dependency, documentation of the completion of rehabilitation must be provided to the NATA Committee on Professional Ethics as a requisite to complete a NATA membership reinstatement or suspension process.

Principle 3: Members Shall Maintain and Promote High Standards in Their Provision of Services

1. Members shall not misrepresent, either directly or indirectly, their skills, training, professional credentials, identity, or services.
2. Members shall provide only those services for which they are qualified through education or experience and which are allowed by the applicable state athletic training practice acts and other applicable regulations for athletic trainers.
3. Members shall provide services, make referrals, and seek compensation only for those services that are necessary and are in the best interest of the patient as delineated by professional statements and best practices.
4. Members shall recognize the need for continuing education and participate in educational activities that enhance their skills and knowledge and shall complete such educational requirements necessary to continue to qualify as athletic trainers under the applicable state athletic training practice acts.
5. Members shall educate those whom they supervise in the practice of athletic training about the Code of Ethics and stress the importance of adherence.
6. Members who are researchers or educators must maintain and promote ethical conduct in research and educational activities. 

Principle 4: Members Shall Not Engage in Conduct That Could Be Construed as a Conflict of Interest, Reflects Negatively on the Athletic Training Profession, or Jeopardizes a Patient’s Health and Well-Being.

1. Members should conduct themselves personally and professionally in a manner that does not compromise their professional responsibilities or the practice of athletic training.
2. All NATA members, whether current or past, shall not use the NATA logo or AT logo in the endorsement of products or services, or exploit their affiliation with the NATA in a manner that reflects badly upon the profession.
3. Members shall not place financial gain above the patient’s well-being and shall not participate in any arrangement that exploits the patient.
4. Members shall not, through direct or indirect means, use information obtained in the course of the practice of athletic training to try and influence the score or outcome of an athletic event, or attempt to induce financial gain through gambling.
5. Members shall not provide or publish false or misleading information, photography, or any other communications in any media format, including on any social media platform, related to athletic training that negatively reflects the profession, other members of the NATA, NATA officers, and the NATA office.

September 2005, Revised 2018

BOC Standards of Professional Practice

Introduction

The BOC Standards of Professional Practice is reviewed by the Board of Certification, Inc. (BOC) Standards Committee and recommendations are provided to the BOC Board of Directors. The BOC Standards Committee is comprised of 5 Athletic Trainer members and 1 Public member. The BOC Board of Directors approves the final document. The BOC Board of Directors includes 6 Athletic Trainer Directors, 1 Physician Director, 1 Public Director and 1 Corporate/ Educational Director.

The BOC certifies Athletic Trainers (ATs) and identifies, for the public, quality healthcare professionals through a system of certification, adjudication, standards of practice and continuing competency programs. ATs are healthcare professionals who collaborate with physicians to optimize activity and participation of patients and clients. Athletic training encompasses the prevention, diagnosis and intervention of emergency, acute and chronic medical conditions involving impairment, functional limitations and disabilities.

The BOC is the only accredited certification program for Athletic Trainers in the United States. Every 5 years, the BOC must undergo review and re-accreditation by the National Commission for Certifying Agencies (NCCA). The NCCA is the accreditation body of the Institute of Credentialing Excellence.

The BOC Standards of Professional Practice consists of two sections:

• Practice Standards
• Code of Professional Responsibility

Practice Standards

Preamble

The primary purpose of the Practice Standards is to establish essential duties and obligations imposed by virtue of holding the ATC® credential. Compliance with the Practice Standards is mandatory. The BOC does not express an opinion on the competence or warrant job performance of credential holders; however, every athletic trainer and applicant must agree to comply with the Practice Standards at all times.

Standards

The BOC does not express an opinion on the competence or warrant job performance of credential holders; however, every Athletic Trainer and applicant must agree to comply with the Standards at all times.

• Standard 1: Direction- The athletic trainer renders service or treatment under the direction of, or in collaboration with a physician, in accordance with their training and the state’s statutes, rules and regulations.
• Standard 2: Prevention- The athletic trainer implements measures to prevent and/or mitigate injury, illness and long term disability.
• Standard 3: Immediate Care- The athletic trainer provides care procedures used in acute and/or emergency situations, independent of setting.
• Standard 4: Examination, Assessment and Diagnosis- The athletic trainer utilizes patient history and appropriate physical examination procedures to determine the patient’s impairments, diagnosis, level of function and disposition.
• Standard 5: Therapeutic Intervention- The athletic trainer determines appropriate treatment, rehabilitation and/or reconditioning strategies. Intervention program objectives include long and short-term goals and an appraisal of those which the patient can realistically be expected to achieve from the program. Appropriate patient-centered outcomes assessments are utilized to document efficacy of interventions.
• Standard 6: Program Discontinuation- The athletic trainer may recommend discontinuation of the intervention program at such time the patient has received optimal benefit of the program. A final assessment of the patients’ status is included in the discharge note.
• Standard 7: Organization and Administration- The athletic trainer documents all procedures and services in accordance with local, state and federal laws, rules and guidelines.

Code of Professional Responsibility

Preamble

The Code of Professional Responsibility (Code) mandates that BOC credential holders and applicants act in a professionally responsible manner in all athletic training services and activities. The BOC requires all Athletic Trainers and applicants to comply with the Code. The BOC may discipline, revoke or take other action with regard to the application or certification of an individual that does not adhere to the Code. The Professional Practice and Discipline Guidelines and Procedures may be accessed via the BOC website, www.bocatc.org.

Code 1: Patient Responsibility

The athletic trainer or applicant:

• Renders quality patient care regardless of the patient’s age, gender, race, religion, disability, sexual orientation, or any other characteristic protected by law
• Protects the patient from undue harm and acts always in the patient’s best interests and is an advocate for the patient’s welfare, including taking appropriate action to protect patients from healthcare providers or athletic training students who are, impaired or engaged in illegal or unethical practice
• Demonstrates sound clinical judgment that is based upon current knowledge, evidence-based guidelines and the thoughtful and safe application of resources, treatments and therapies
• Communicates effectively and truthfully with patients and other persons involved in the patient’s program, while maintaining privacy and confidentiality of patient information in accordance with applicable law
  • Demonstrates respect for cultural diversity and understanding of the impact of cultural and religious values
• Develops and maintains a relationship of trust and confidence with the patient and/or the parent/guardian of a minor patient and does not exploit the relationship for personal or financial gain
• Does not engage in intimate or sexual activity with a patient and/or the parent/guardian of a minor patient
• Informs the patient and/or the parent/guardian of a minor patient of any risks involved in the treatment plan
  • Does not make unsupported claims about the safety or efficacy of treatment

Code 2: Competency

The athletic trainer or applicant:

• Engages in lifelong, professional and continuing educational activities to promote continued competence
• Complies with the most current BOC recertification policies and requirements

Code 3: Professional Responsibility

The athletic trainer or applicant:

• Practices in accordance with the most current BOC Practice Standards
• Practices in accordance with applicable local, state and/or federal rules, requirements, regulations and/or laws related to the practice of athletic training
• Practices in collaboration and cooperation with others involved in a patient’s care when warranted; respecting the expertise and medico-legal responsibility of all parties
• Provides athletic training services only when there is a reasonable expectation that an individual will benefit from such services
• Does not misrepresent in any manner, either directly or indirectly, their skills, training, professional credentials, identity or services or the skills, training, credentials, identity or services of athletic training
  • Provides only those services for which they are prepared and permitted to perform by applicable local, state and/or federal rules, requirements, regulations and/or laws related to the practice of athletic training
• Does not guarantee the results of any athletic training service
• Complies with all BOC exam eligibility requirements
• Ensures that any information provided to the BOC in connection with exam eligibility, certification recertification or reinstatement including but not limited to, exam applications, reinstatement applications or continuing education forms, is accurate and truthful
• Does not possess, use, copy, access, distribute or discuss certification exams, self-assessment and practice exams, score reports, answer sheets, certificates, certificant or applicant files, documents or other materials without proper authorization
• Takes no action that leads, or may lead, to the conviction, plea of guilty or plea of nolo contendere (no contest) to any felony or to a misdemeanor related to public health, patient care, athletics or education; this includes, but is not limited to: rape; sexual abuse or misconduct; actual or threatened use of violence; the prohibited sale or distribution of controlled substances, or the possession with intent to distribute controlled substances; or improper influence of the outcome or score of an athletic contest or event
• Reports any suspected or known violation of applicable local, state and/or federal rules, requirements, regulations and/or laws by him/herself and/or by another Athletic Trainer that is related to the practice of athletic training
• Reports any criminal convictions (with the exception of misdemeanor traffic offenses or traffic ordinance violations that do not involve the use of alcohol or drugs) and/or professional suspension, discipline or sanction received by him/herself or by another Athletic Trainer that is related to athletic training
• Cooperates with BOC investigations into alleged illegal or unethical activities. Cooperation includes, but is not limited to, providing candid, honest and timely responses to requests for information
• Complies with all confidentiality and disclosure requirements of the BOC and existing law
• Does not endorse or advertise products or services with the use of, or by reference to, the BOC name without proper authorization
• Complies with all conditions and requirements arising from certification restrictions or disciplinary actions taken by the BOC, including, but not limited to, conditions and requirements contained in decision letters and consent agreements entered into pursuant to Section 4 of the BOC Professional Practice and Discipline Guidelines and Procedures.

Code 4: Research

The athletic trainer or applicant who engages in research:

• Conducts research according to accepted ethical research and reporting standards established by public law, institutional procedures and/or the health professions
• Protects the human rights and well-being of research participants
• Conducts research activities intended to improve knowledge, practice, education, outcomes and/or public policy relative to the organization and administration of health systems and/or healthcare delivery

Code 5: Social Responsibility

The athletic trainer or applicant:

• Strives to serve the profession and the community in a manner that benefits society at large
• Advocates for appropriate health care to address societal health needs and goals

Code 6: Business Practices

The athletic trainer or applicant:

• Does not participate in deceptive or fraudulent business practices
• Seeks remuneration only for those services rendered or supervised by an AT; does not charge for services not rendered
  • Provides documentation to support recorded charges
  • Ensures all fees are commensurate with services rendered
• Maintains adequate and customary professional liability insurance
• Acknowledges and mitigates conflicts of interest

Version 3.1 - Published October 2017, Implemented January 2018

Management Strategies Regarding Athletic Training Program Authority and Athletic Training Facility Operations

The Athletics Director or designee shall be responsible for administering the following policies and procedures pertaining to the CMS Sports Medicine Program authority and oversight of and athletic training room facility operations.

Sports Medicine Program Scope of Responsibilities 

The Claremont-Mudd-Scripps Sports Medicine Program (CMSSMP) shall be led by a BOC certified athletic trainer and shall be responsible for delivering the following student-athlete health care services:

Individualized Student-Athlete Care 

CMSSMP shall provide individualized student-athlete care that includes:

1. Performing assessments of health status
2. Making physician referrals for diagnosis and health care strategy instructions
3. Developing health care plans based on physician diagnosis and instructions
4. Implementing health care treatment
5. Evaluating the success of health care interventions.

Health Care Intervention 

CMSSMP shall implement health care interventions targeted at returning student-athletes to pre-injury performance levels as quickly and as safely as possible with maximum attention to prevention of reoccurrence resulting from incomplete rehabilitation.

Documentation 

CMSSMP shall be responsible for maintaining complete documentation of student-athlete health including: student-athlete pre-participation health care screening, injury assessment notes, physician diagnosis and consultation records, as well as treatment logs and clearance documentation.

Privacy 

CMSSMP shall respect the student-athlete’s right to privacy by protecting confidential information in accordance with HIPPA regulations.

Student-Athlete Education 

CMSSMP shall be committed to the highest levels of student-athlete communication, education and counseling in all health care situations.

Collaboration and Coordination with Other Health Care Professionals and Agencies 

The CMSSMP is responsible for ensuring collaboration and coordination of student-athlete treatment with physicians, rehabilitation specialists, and other resources and agencies with the goal of producing the highest levels of student-athlete health care.  In particular, CMSSMP is responsible for consultation with appropriate licensed medical practitioners in the design of treatment strategies and the clarification of any instructions or treatment regimens.

Health Care Staff Supervision 

The Assistant Athletic Director for Sports Medicine, Performance and Health shall be responsible for supervising and evaluating the performance of CMSSMP personnel of the institution and ensuring that assignments of staff are made with full consideration of the professional training and experience of each employee.

Professional Development 

The Assistant AD for Sports Medicine, Performance and Health shall be responsible for ensuring the continued professional development of himself/herself and all other CMSSMP employees.

Medical Physician Supervision and Authority

Team Physician 

The Assistant AD for Sports Medicine, Performance and Health shall select and appoint a Team Physician who shall contribute to and oversee the:

• Recruitment of consulting physicians and approval of the use of physicians for second opinions
• Provision of the highest level of medical care of all student-athletes
• Supervision and evaluation of the performance of the CMSSMP staff and making recommendations for the improvement of the CMSSMP
• Advisement on development, implementation and progression of rehabilitation protocols
• Making of the final decision on return to participation of injured or ill student-athletes
• Attendance of home athletics events in sports requiring attendance of a physician or arranging for consulting physician coverage of such event.
• Be available by telephone for consultation of student-athlete injuries or illnesses.

Student-Athlete Use of Private Physicians

Student-athletes may use the services of any physician at their own expense and without the approval of the Team Physician or Assistant AD of Sports Medicine, Performance and Health. If prior approval is obtained, the physician expenses may be reimbursable by the Institution.

Consulting Physicians

Consulting physicians appointed by the CMSSMP shall be identified in the areas of orthopedics, gynecology, dentistry, internal medicine, allergies and immunology, dermatology, cardiology, ophthalmology and other specialty areas as determined by student-athlete health care needs. The responsibilities of the Consulting Physician are:

• Examine, diagnose and recommend treatment for an ill or injured student-athlete in his or her respective specialty area when contacted by the Team Physician or CMSSMP staff
• Advise the Team Physician and CMSSMP staff of desirable injury prevention measures that should be utilized by the CMSSMP
• Be available for telephone consultation when contacted by the Team Physician or CMSSMP staff

 Sports Medicine Fellowship Program

CMSSMP is a teaching facility for the Kaiser Permanente- Fontana Sports Medicine fellowship program. Physicians are selected by the Directors of the program and assigned a position at CMS on an annual rotating basis. Physicians will conduct weekly clinic in the CMS athletic training facility and the physician will attend all football games and other events/contests as assigned.

CMSSMP Staff

The Assistant Athletic Director of Sports Medicine, Performance and Health, and all full-time athletic training staff, shall be certified by and in good standing with the Board of certification (BOC) and shall serve under the direction and supervision of the Team Physician and/or consulting physicians in all matters of a medical nature.  In administrative and non-medical matters, the Asst. AD of Sports Medicine, Performance and Health shall report to and be supervised by the Athletics Director or designee.  The Asst. AD for Sports Medicine, Performance and Health shall be responsible for providing exemplary programs in health care delivery, care, prevention and treatment of athletics injuries, rehabilitation, and sports nutrition.  The Asst. AD for Sports Medicine, Performance and Health shall also be responsible for supervising all sports medicine personnel and athletic training student aides, coordinating the involvement of all health care professionals and agencies, maintaining a high quality athletic training facility and completing all administrative duties as assigned by the Athletics Director or designee.

Assistant athletic trainers are responsible for fulfilling the duties as assigned by the Asst. AD for Sports Medicine, Performance and Health. They are required to present themselves in a professional manner and adhere to the standards set by the Asst. AD for Sports Medicine, Performance and Health. Athletic training program standards of care shall conform to the requirements contained in the most recent issue of the NCAA Sports Medicine Handbook.

Allied Health Care Professionals

The employment and/or association on a paid or voluntary basis of allied health care professionals (i.e. chiropractors, massage therapists, nutritionists, etc.) requires the approval of the Team Physician or Assistant AD of Sports Medicine, Performance and Health according to the following required procedures.

Provision of Service in a Professional Setting

CMSSMP staff and coaches are responsible for ensuring that allied health care personnel provide their services in professional settings (i.e., athletic training facility, locker room, etc.) as opposed to home, dormitory, or hotel rooms.  The work of such personnel must occur under the direct supervision of a full-time member of the coaching or CMSSMP staff.

Documentation

Allied health care professionals are required to provide documentation of all evaluations and treatments rendered to CMSSMP staff.

Contracted Athletic Trainers

In cases where additional staffing is needed for practice/event coverage, the contracted athletic trainer shall be BOC certified and knowledgeable of and abide by the standards expected of the CMSSMP. Additionally, the contracted AT will provide their own liability insurance. The contracted AT is responsible for providing documentation of all evaluations and treatments rendered to the CMSSMP staff.

Athletic Trainer Coverage of Practice, Competition and Other Activities

Determination

The Assistant AD of Sports Medicine, Performance and Health shall be responsible for determining assignments of all CMSSMP personnel.

Practice and Competition Coverage

The Assistant Athletic Director for Sports Medicine, Performance and Health shall be responsible for determining assignments of all CMSSMP personnel. CMSSMP staff shall provide coverage of all in-season (traditional) practices in contact sports or sports with elevated injury risks, including but not limited to:  football, basketball, volleyball, softball, baseball, soccer, lacrosse and track and field. Non-traditional practices and strength & conditioning sessions shall be covered to the best of the ability of the CMSSMP, at the discretion of CMSSMP staff, without affecting coverage of in-season sports. All head coaches and full time assistant coaches shall be CPR/AED/First-aid certified. CMSSMP staff shall provide coverage at all home competitive events in all sports.

Athletic Training Students

Athletic training students will be trained by the CMSSMP staff in basic skills and techniques needed for the daily operation of the sports medicine facility. Students shall be current in CPR/First-aid/AED and blood borne pathogen certifications. An athletic training student shall be assigned to each home event and practice based on availability with the intention of assisting the covering athletic trainer in any way deemed necessary.

Special Events, Camps and Clinics

The assignment of CMSSMP personnel to special events shall be made on a “request only/dependent on availability” basis.  Athletic trainer fees and the cost of all expendable supplies shall be charged to the event budget.  Such services shall be requested at least one month in advance.

Non Intercollegiate Sport/General Student Access to Care and Facilities

 Non intercollegiate sport students (club, intramural, physical education, recreation) will be seen on a consult basis only. Injuries will be evaluated and the student will be directed to an appropriate health care provider or given advice on care of the injury. The injury will be documented and a copy of the injury report sent via e-mail to Student Health Services, the athlete, as well as the coach if applicable. Concussions to the non-athlete will be evaluated, documented and the appropriate guidelines given. Information will be forwarded to Student Health Services and the DoS of the student’s institution. Students will be instructed to make an appointment with Student Health for continued care and return to activity/class recommendations. Club sport activities and practices will not be covered by the sports medicine staff and injuries are not covered by the CMS excess insurance policy.

Home Event Planning

It is the responsibility of the facility manager to provide for the safety of student-athletes, officials and spectators at each home event.  CMSSMP personnel shall participate in pre-event planning, assist in the provision of health care services as determined in such planning meetings, follow all established emergency medical procedures and provide expendable first aid supplies as determined in the planning meeting. The CMSSMP will schedule the Advanced Life Saving (ALS) stand-by ambulance coverage for all home football contests and other home events as needed.

Sports Medicine Facility

Standards

The CMSSMP is responsible for maintaining a sports medicine facility that contains all standard modalities for treatment, sufficient consumable supplies to meet the needs of the CMSSMP and that such facility is operated with the highest standard of care and cleanliness that diminishes the possibility of contamination by blood-borne pathogens or infectious diseases. 

Storage of Drugs and Supplements 

All prescription and non-prescription drugs and supplements shall be kept in locked cabinets and procedures shall be in place to adequately supervise their distribution and use.

Training Room Dress and Conduct 

The CMSSMP staff shall be responsible for establishing standards of dress for treatments and conduct of student-athletes in the sports medicine facility and enforcing such standards to ensure the health and safety of its occupants.

Safety Signage 

Safety procedure signage is posted on all modalities, the sports medicine code of conduct and other safety related signage is prominently displayed in appropriate areas of the sports medicine facillity.

Supervision 

Sports medicine facilities shall be locked at all times when they are not under the supervision of an assigned CMSSMP staff member.

Electric Cart Usage

The use of an electric golf cart/truck is necessary to the operation of the CMSSMP. The cart is to be used solely for the delivery of medical equipment, water and ice to/from facilities and the transport of injured athletes. All drivers must be approved and certified and the CMC policy on cart usage shall be followed.

Hydrotherapy Pools

Appropriate attire (swim suits, shorts, sports bras) shall be worn at ALL times. Pools may be used only when supervised by CMSSMP staff. Inappropriate behavior will not be tolerated and may result in loss of use. Athletes must shower prior to use. Pools will be maintained by CMSSMP staff and CMC facilities staff to standard OSHA guidelines.

Management Strategies Regarding Medical Screening, Records, Insurance and Emergencies

Student-Athlete Records

All student-athlete medical and treatment records shall be recorded and stored online in the Athletic Trainer System (ATS) database, ©Keffer Development Services LLC.

Medical Screening

Student-athletes have a responsibility to truthfully and fully disclose their medical history and to report any changes in their health to the team’s sports medicine staff.  Prior to participation in any practice, competition, or out-of-season conditioning activities, student-athletes shall be required to undergo a medical examination administered or supervised by a physician (e.g., family physician, team physician, MD or DO). This comprehensive exam must be completed annually. The examination must be administered no earlier than 3 months prior to the first sport of participation of an academic year. This examination shall include a comprehensive health history, a current physical exam, with emphasis on the cardiovascular, neurologic, and musculoskeletal evaluation. 

Immunizations

The pre-participation screening CDC recommended immunizations shall be kept at the Student Health Center as part of the athlete’s entrance medical files.

Follow-up Examinations

Those student-athletes who have sustained a significant injury or illness during the sport season shall be required to complete a follow-up examination to re-establish medical clearance before resuming participation in their respective sports. This policy also applies to pregnant student-athletes following delivery or pregnancy termination. Clearance for individuals to return to activity is solely the responsibility of the athletic trainers, Team Physician or their designated representative.

Screening for Sickle Cell Trait (SCT)

Given the danger of acute exertional rhabdomyolysis (explosive muscle breakdown) from sickle cell trait, all student-athletes shall be screened for SCT, shall submit proof of a prior negative test, or shall sign a written release declining the test.  (NCAA, 2011-12)

Medical Records

Medical records shall be maintained and updated on ATS during the student-athlete’s career and shall include:

• A record of injuries, illnesses, new medications or allergies, pregnancies and operations, whether sustained during the competitive season or the off-season
• Referrals for and feedback from consultation, treatment or rehabilitation
• Record of rehabilitation care, treatment and clearances to participate for each injury or illness
• A comprehensive student-athlete and family medical history, health-status questionnaire and an updated health-status questionnaire each year thereafter
• Written permission, signed annually by the student-athlete, which authorizes the release of insurance and  medical information to CMSSMP
• Primary (parent, self, employer) Insurance Information
• Concussion Statement Form signed annually
• Acceptance of Risk and Authorization to Treat form signed annually
• ADHD Medication Information Form
• Emergency Contact Information

Confidentiality 

Medical records and the information they contain shall be created, maintained and released in accordance with HIPPA and FERPA regulations. All personnel who have access to a student-athlete’s medical records shall be responsible for conformance with such guidelines and maintaining the student-athlete’s right to privacy.

Insurance

Each student athlete shall be covered by individual, parental or institutional medical insurance to defray significant injury or illness. CMSSMP carries an excess policy that covers all expenses not covered by the athlete’s primary insurance. Covered expenses must be the direct result of participation in intercollegiate athletic activities. All claims will be considered and administrated by the Head Athletic Trainer under the guidelines set in the Insurance Statement signed annually by the athlete.

Facility Emergency Action Plan

The CMSSMP, in consultation with campus safety, institutional risk managers, and local emergency medical services shall be responsible for the development of an emergency action plan specific to each athletics facility designating responsibilities of specific personnel (i.e. coaches, sports medicine professionals, athletic training students, and event supervisors), emergency equipment needed to carry out emergency tasks and the location of equipment, and clear instructions for communication to appropriate emergency care service providers. Each plan shall conform to best practices as recommended by the National Association of Athletic Trainers (NATA) and the National Collegiate Athletic Association (NCAA). Link Hard copies of each plan can be found in the red binder in the Sports Medicine Facility. Electronic versions are kept in the ATR Share file within “box”. Emergency action plans shall be reviewed with coaches and facility supervisors annually and recommended more frequent review depending on the nature of the facility and event being hosted. The Emergency Management Coordinator for the Claremont Consortium shall review and approve emergency plans.

Sudden Cardiac Arrest and the Use of Automated External Defibrillators

Because sudden cardiac arrest (SCA) is the leading cause of death in student-athletes, the use and availability of automated external defibrillators (AEDs) shall be a part of the institution’s Emergency Action Plan (EAP) for every athletics venue. Certification in cardiopulmonary resuscitation techniques (CPR), first aid, and prevention of disease transmission as outlined by OSHA guidelines is required for all athletics personnel associated with practices, competitions, skills instruction, and strength and conditioning. New staff engaged in these activities must comply with these rules within three months of employment.

Convenient Access

Access to early defibrillation is essential with a target goal of less than 3 to 5 minutes from the time of collapse to the first shock strongly recommended. Thus, all AED units shall be located in close proximity to the venue activity area and such location shall be clearly specified in the emergency medical plan.

Emergency Equipment Inspection

The CMSSMP shall schedule regular inspections of all emergency medical equipment. Inspection and maintenance of campus AED’s is scheduled and carried out by CMC Maintenance & Facilities.

Emergency Medical Equipment

The following emergency medical equipment shall be available at all athletics venues and shall only be used by staff members trained in its use:

• Blood kits for visiting teams
• Automated emergency defibrillator (AED) and AED supplies (scissors, razor, pads and towel)
• Pocket mask or barrier-shield device for rescue breathing
• Emergency oxygen with bag-valve mask (located in sports medicine facility)

Note: All student-athletes needing prescription epi-pens, inhalers or other emergency medications utilized on an as needed basis are responsible for bringing those to each practice, competition/game, and/or otherwise not-specified CMS athletic event. Or they shall, provide the CMSSMP staff with a back-up.

Equipment Removal

Traumatic spinal cord injury (SCI) is a devastating condition that merits concerted focus due to its high rates of morbidity and mortality. Preparation is essential and includes education and training, maintenance of emergency equipment and supplies, and implementation of an EAP. An athletic trainer shall be on site during all home sporting events. If medical personnel are not present, procedures are in place for implementing the EAP with coaches trained as first responders to ensure appropriate care prior to the arrival of trained medical personnel.

Equipment Removal Personnel

Protective athletic equipment should be removed prior to transport to an emergency facility for an athlete-patient with suspected cervical spine instability. Equipment removal should be performed by at least three rescuers trained and experienced with equipment removal (e.g., certified athletic trainer, graduate assistant athletic training student, team physician, EMS personnel) at the earliest possible time. If fewer than three people are present, the equipment should be removed at the earliest possible time after enough trained individuals arrive on the scene. EMS will be responsible for leading the transfer to the long spine board.

Rationale and Techniques for Equipment Removal & Immobilization

Recent changes in some emergency medical services (EMS) protocols have impacted management of spine injuries in the field and during preparation for and transportation to hospital emergency departments. In the past, it was recommended that protective equipment (e.g., helmets and shoulder pads in football, hockey and lacrosse) be left in place for transport and removed upon arrival in the hospital Emergency Department.

It is essential and now recommended that, when appropriate, in an emergency situation with equipment- intensive sports (e.g., helmets and shoulder pads in football, hockey and lacrosse), the protective equipment be removed prior to transport to the hospital. Rescuers should be able to recognize when it is NOT appropriate to remove equipment on the field of play and have a plan to best manage the patient. The rationale for consideration of equipment removal on the field is rooted in, but not limited to, the following concepts:

1. Advances in equipment technology
2. Equipment removal should be performed by those with the highest level of training. In most cases, athletic trainers have been exposed to more equipment removal training than many other members of the medical team. As a result, individuals on the field may have a greater knowledge of equipment removal procedures than the hospital emergency department staff.
3. Expedited access to the athlete-patientpatient’s chest and airway  for enhanced provider care Chest access is prioritized

A rigid cervical stabilization device should be applied to spine injured athlete-patient with spinal injuries prior to transport.

1. A rigid cervical collar should be applied at the earliest and most appropriate time possible during pre- hospital procedures. With practice, cervical collars can be placed and removed with manual, in-line stabilization and potentially minimal risk.
2. The medical team needs to continue manual, in-line stabilization even after the rigid cervical collar is applied. Several research studies have demonstrated that rigid cervical collars are not effective in controlling cervical spine motion in all planes of movement. Manual, in-line stabilization must be maintained until the athlete-patient has been stabilized on a full body immobilization device and a head immobilization device has been applied.

Athlete-patients with spinal injuries should be transported using a rigid immobilization device.

1. The transport of the spine injured athlete-patient requires special considerations which may include, but are not limited to the mechanism of injury, size of the athlete-patient, equipment worn by the athlete-patient, and the number and skill level of the sports medical team members.
2. Throughout the years different terminology has been used by pre-hospital medical care teams to describe procedures used to prevent iatrogenic spinal cord injuries. Initially spinal traction was used and was followed by spinal immobilization. Sports medical care teams must now recognize the concepts of spinal motion restriction (SMR) as compared to spinal immobilization. SMR implies that true spinal immobilization cannot be obtained even with the patient securely strapped to a spine board. Like spinal immobilization, the premise of SMR is to prevent further harm to a spinal cord or column injury.
3. Criteria for the use of SMR guidelines and immobilization devices should include:

• Blunt trauma with altered level of consciousness
• Spinal pain or tenderness
• Neurologic complaint (e.g., numbness or motor weakness)
• Anatomic deformity of the spine
• High-energy mechanism of injury and any of the following:
  • Drug or alcohol intoxication
  • Inability to communicate
  • Distracting injury

4. Recent publications have expressed concern related to the use of the long spine board due to potential harmful effects to the patient if the patient remains on the long spine board for an extended period of time. However, in the case of a potentially spinal cord injury it is recommended that a long spine board or other immobilization device be used for transport. The Emergency Dept. medical team is responsible for transferring the athlete-patient off the spine board to the appropriate hospital bed for further care.

Techniques employed to move the athlete-patient with a spinal injury from the field to the transportation vehicle should minimize spinal motion.

1. The spine injured athlete-patient should be transferred to the long spine board or vacuum mattress using a technique that limits spinal motion.
2. In the case of a supine positioned athlete, the medical team should use the 8-person lift (previously described as the six-plus lift) to move the athlete-patient to the long spine board.
3. The scoop stretcher may be employed to lift the supine athlete-patient from the field.
4. In the case of a prone positioned athlete, the medical team should position the spine board and use a log roll push technique to place the athlete-patient on to the long spine board.

Spine injured athlete-patients shall be transported to a hospital that can deliver immediate, definitive care for these types of injuries.

1. Pomona Valley Hospital Medical Center is the preferred destination for transport of the critically injured athlete. Final determination will be made by the attending emergency personnel.
2. If definitive care is not readily available, spine injured athlete-patients should be transported to the nearest hospital for stabilization and possible air medical evacuation to the nearest trauma center. Attempts should be made to avoid this extra delay in definitive care as the patient in this scenario might have improved outcomes with expeditious definitive management.
3. Emergency medical teams should keep in mind that every time the spine injured athlete-patient is moved, the chance for additional neurological compromise increases. For this reason, transfer of the athlete- patient in the pre-hospital setting and within the ED should be kept to a minimum and appropriate transfer devices should be used.
4. ED staff must avail themselves of training modules in the event an athlete arrives with equipment in place.

Management Strategies Regarding the Catastrophic Incident Management

Introduction and Definition of a Catastrophic Accident

The Claremont-Mudd-Scripps Athletics Department’s Catastrophic Incident Guideline will be activated when the following catastrophic incidents (CI) occur:

Sudden Death of a Student-Athlete, Coach, or Staff Member

• Death during competition, practice, or conditioning
• Death during travel
  • CMS Athletics Department official business
  • Personal (e.g. automobile, airline accidents)
• Non-athletic accidents ( e.g. falls at home)
• Unknown medical anomalies (e.g. heart attacks, stroke, illness)
• Victim of a crime (e.g. homicide)
• Suicide

Disability/Quality of Life Altering Injuries

• Either during CMS Athletics Department participation and/or travel, or during non-athletic activities.
• Spinal Cord Injury-resulting in partial or complete paralysis
• Loss of Paired Organ
• Severe Head Injury
• Injuries resulting in severely diminished mental capacity or other neurological injury that results in inability to perform daily functions (e.g. coma)
• Irrecoverable loss of speech or hearing (both ears) or sight (both eyes) or both arms or both legs or one arm and one leg

Catastrophic Incident Management Team (CIMT)

• President of CMC
• Vice President of Student Affairs
• Dean of Students
• Dean (of Students) on Call
• Vice President for Planning and Administration/ General Counsel
• Associate Vice President for Public Affairs & Communications
• Athletics Director
• Head Athletic Trainer
• Emergency Preparedness and Safety Manager
• Team Physician
• Sports Information Director
• The Claremont Colleges Services (TCCS) Risk Management
• TCCS Student Health Services
• Others as deemed necessary by the CIMT

Immediate Action Plan

The following action plan will be implemented by CIMT in order to properly manage a catastrophic incident. The CMS Athletics Department working with the CIMT will keep in mind the following goals while applying these steps:

• Gather all pertinent facts regarding the incident accurately and expeditiously
  • Name of the Athlete/Individual
  • School They Attend
  • Event
  • Location Where Incident Occurred
  • Name/Location of Facility Transported to
  • Nature of Injury
  • Contact Person Phone Numer
• Accurately document all events, especially list all participants and witnesses, and if possible contact information
• Secure any or all available materials/equipment involved in the incident
• Respect the dignity of the individuals involved
• Immediate coordination of communication within the catastrophic incident management team (CMIT)
• Only the President, College Spokesperson, Vice President of Communications, or individuals they designate, are to speak concerning the incident to family members, other staff members, student-athletes or coaches- No one else has clearance to speak concerning the incident
• No one from the College is to speak to the media or any agency outside of the College concerning the incident.  The exception to this mandate will be any requested interview by law enforcement or fire authority/paramedic personnel during the course of that agency’s investigation. Instruct student-athletes that they are not to speak to anyone regarding the incident
• Any communication with the media is handled through the College Spokesperson. All information deemed appropriate for release to the media will be determined by College Spokesperson or President.

Home Practice/Game

The CMS Emergency Action Plan with regards to a home practice/game will be followed if a CI occurs

1. The athletic trainer will contact Campus Safety at (909) 607-2000 (or 911) for emergency response, who will then contact the CMC Dean on Call.
   1. If 911 is called, a secondary phone call to Campus Safety shall be made to begin the notification process of the CMC Dean on Call.
2. The athletic trainer will ask Campus Safety to have the Dean on call return their call at the phone number provided at that time to gather pertinent information.
3. A CMS athletic trainer, a member of the coaching staff, and/or other personnel will accompany the injured student-athlete to the medical facility with the injured student/athlete’s emergency medical or individual insurance information (In the event that the practice/game continues, once the game/practice is completed, the athletic trainer will immediately proceed to the medical facility).
4. Once at the medical facility, the designated individual will contact the athletic trainer directly with any medical updates.
5. The Chain of Command for CI’s will then be followed.
6. The athletic trainer will maintain communications with the VP for Student Affairs or Dean of Students to provide regular updates.

Away Practice/Game

The CMS athletic trainer or Head Coach will assist in the hosting venue’s practice/game emergency action plan if a CI occurs.

• If no athletic trainer is present the Head Coach will activate the EAP.  After the initial emergency response has been managed the coach shall then contact the Head Athletic Trainer directly on his/her cellular phone.

1. The athletic trainer will contact Campus Safety at (909) 607-2000 (or 911) for emergency response who will contact the CMC Dean on Call.
   1. If 911 is called, a secondary phone call to Campus Safety shall be made to begin the notification process of the Dean on Call.
2. The athletic trainer will ask Campus Safety to have the Dean on Call return their call to gather pertinent information.
3. An athletic trainer, a member of the coaching staff, and/or other personnel will accompany the injured student-athlete to the medical facility with the injured student-athlete’s emergency medical/insurance information.
   1. Once the game/practice is completed, the athletic trainer will immediately proceed to the medical facility.
4. Once at the medical facility, the designated individual will contact the athletic trainer directly with any medical updates.
5. The Chain of Command for CI’s will then be followed.
6. The athletic trainer will maintain communications with the VP for Student Affairs or Dean of Students to provide regular updates.

Guidelines to use during a serious on-field player injury

1. Players and coaches should go to and remain in the bench area once medical assistance arrives. Adequate lines of vision between the medical staffs and all available emergency personnel should be established and maintained
2. Players, parents and non-authorized personnel should be kept a significant distance away from the seriously injured player or players
3. Players or non-medical personnel should not touch, move or roll an injured player.
4. Players should not try to assist a teammate who is lying on the field (i.e. removing the helmet or chin strap, or attempting to assist breathing by elevating the waist)
5. Players should not pull an injured teammate or opponent from a pileup
6. Once medical staff members begin to work on an injured player, they should be allowed to perform services without interruption or interference
7. Players and coaches should avoid dictating medical services to the athletic trainers or team physicians or taking up their time to perform such services.

Chain of Command and Areas of Action

After being informed of a catastrophic incident, the following individuals should be notified by the Dean of Students or VP of Student Affairs to commence their responsibilities as set forth below:

• During CMS Athletics Department participation/travel: Head Athletic Trainer or Director of Athletics
• Non CMS Athletics Department activities: Director of Athletics

Director of Athletics

• Notified by Campus Safety or Head Athletic Trainer of a catastrophic incident.
• Notifies Human Resources (only if incident is related to an employee)
• Notifies additional athletic department administrative staff (SWA, Assistant Athletic Directors and Sports Information Director)
• In the event the CI is non-athletic, the Director of Athletics notifies the Head Coach of the Sport
• Notifies NCAA Faculty Athletics Representative

Dean of Students

Will additionally contact and work with the following as the incident progresses:

• Notifies emergency contact(s) of student-athlete
• Notifies Dean of Students for Scripps or Harvey Mudd if student-athlete attends those institutions.
• Help facilitate efforts of Athletics Department and Counseling Services and work together as the Catastrophic incident Stress Management Team (for counseling of team, coaches, staff)
• TCCS Student Health Services
• Other students as needed

Head of Sports Medicine Services/ Head Athletic Trainer

• Notifies Director of Athletics, Head Team Physician, Sports Medicine Staff
• Notifies Head Coach if incident occurs during non-practice participation, or when coach may not be present (e.g. conditioning)
• Coordinates, along with Head Team Physician, communication with any physicians involved in the catastrophic incident medical care
• Communicates with Sports Information Director
• Provides any insurance information to hospital
• Notifies NCAA Catastrophic Injury Service Insurance Carrier

Team Physician

• Communicates with Director of Athletics and Head Athletic Trainer on medical facts and events
• Communicates with any local medical personnel hospital or medical facilities regarding medical facts of the catastrophic incident
• Works with Head Athletic Trainer in providing information for NCAA insurance

CMS Athletic Department Administrative Staff

• Sports Information Director: coordinate any media release with the Director of Athletics, Head Team Physician, and Head Athletic Trainer along with the Associate Vice President for Public Affairs

NO RELEASE will be made until parents/guardians are informed and information concerning incident has been verified for accuracy. In the event of possible negligence, legal counsel must be advised immediately and no media statement will be made until risk management and legal counsel have approved media statement.

• Athletic Department Business Manager and/or Athletic Office Coordinator: will coordinate any travel plans and housing for parents, staff, coaches or team
• Senior Woman’s Administrator and all Assistant Directors of Athletics available to assist in process as assigned by CIMT

Coaching and Support Staff

• Notify Director of Athletics and Head Athletic Trainer of Catastrophic Incident
• Follow Immediate Action Plan
• Encourage Student-Athletes to not discuss incident until cleared to do so by CMS Athletic Department
• Support Student-Athletes and facilitate CI Guidelines as outline

TCCS Risk Manager

• Notify CMS Insurance Carrier
• Enact any Catastrophic Incident procedures for College Administration
• Work collaboratively with CMS Athletic Department to gather incident facts
• Communicate with CMC General Counsel Legal Counsel

Counseling Services

• On Call 24 Hours Daily
• Activate Catastrophic Incident Stress Management Team to provide immediate grief counseling post-incident to student-athletes, coaches, or staff members

Disability Services

• Serve as faculty liaison to campus for Athletic Department
• Notifies professors of incident and impact on class/grades

Criminal Circumstances (Accident, Assault, Homicide, Suicide)

Campus Safety

• Campus Safety notified immediately of catastrophic incident involving possible criminal activity
• Director of Campus Safety notified
• Campus Safety communicates with Claremont Police Department
• Campus Safety communicates information as appropriate to VP for Student Affairs or Dean of Student

Away Contests-Coaches, Administrators and Staff Members

• Lead athletic trainer will immediately notify Director of Athletics and Head Athletic Trainer of Catastrophic Incident
• Work with local hospital, Sports Medicine Staff, Athletic Department or Police to assist in process and gather information to update the Director of Athletics and/or Director of Athletic Training Services
• The Head Coach and/or Administrator remains on site after team departs to coordinate communication and arrangement with College Administration until relieved by a College Representative
• TCCS Risk Manager is notified of the incident

Summary Chronicle

• A detailed written summary chronicle will be prepared following any catastrophic incident which identifies and explains the activities of those who participated in and responded to the incident
• This chronicle will be used to critique the process, its efficiency and effectiveness, and will be used as the basis for review of the procedures

Management Strategies Regarding Blood Borne Pathogens and Infectious Diseases

The Head Athletic Trainer or their designee shall be responsible for the administering the following policies and procedures pertaining to blood-borne pathogens and infectious diseases.

General - Hepatitis B (HBV) and Human Immunodeficiency Virus (HIV)

Both HBV and HIV viruses can be transmitted through sexual contact and exposure to infected blood or blood products. The current state of medical knowledge of Hepatitis C (HCV) is incomplete but it does appear to be transmitted by blood. No definite guidelines exist for HCV.

HBV Infection

HBV infection generally results in reversible liver damage and full recovery. However, a small number of cases will result in fulminate hepatitis and permanent liver damage and death. Recovered individuals will clear the virus and subsequently develop immunity and are no longer infectious. However, about 5-10% of acutely infected individuals become chronically infected and are considered HBV carriers. The risk of HBV transmission is presumed to be low. However, athletes participating in contact sports, may be at increased risk.

Acute HBV Infection

Participation by athletes who are acutely infected with HBV will generally depend on their symptomatology, severity of illness, and presence of abnormal labs, just as with any other viral illness. Therefore, the simple presence of HBV infection does not preclude athletic participation.  However, NCAA recommendations (NCAA Sports Medicine Handbook 2009-2010) shall be followed in the case of acute HBV infection: “If a student athlete develops acute HBV illness, it is prudent to consider removal of the individual from combative, sustained close -contact sports until loss of infectivity is known. (The best marker for infectivity is the HBV antigen, which may persist up to 20 weeks in the acute stage). Student athletes in such sports who develop chronic HBV infections (especially those who are e-antigen positive) should probably be removed from competition indefinitely, due to the small but realistic risk of transmitting HBV to other student athletes.”

HIV Infection

HIV infection is considered, at this time, to be a chronic illness which can progress to AIDS (Acquired Immunodeficiency Disease) and death. Some HIV positive individuals will rapidly progress to AIDS while others may show no clinical symptoms of acute or chronic disease for many years.

Asymptomatic HIV

Participation by athletes who are HIV positive depends on their level of health. In those individuals who are symptom-free and without immunologic deficiencies, athletic participation should not be restricted. Athletic participation has not been shown to be detrimental to the health of the asymptomatic HIV positive athlete. However, studies with HIV athletes engaged in high intensity training over long periods of time have not been done. It is important that the athlete receive care from a health care provider skilled in the care of HIV positive patients. The athlete will also be encouraged to discuss their medical condition with the team physician. The athlete’s personal physician, and the team physician can then coordinate medical care and discuss with the athlete what level of participation is healthy and safe.

Risk of Transmission

Valid documentation of a case of HIV transmission in sport does not exist. There are no epidemiologic studies to determine the precise risk of transmission. The risk could increase in sustained close contact sports such as wrestling. However, studies do suggest the risk is extremely low. The Institution shall therefore follow NCAA recommendations (Sports Medicine Handbook 2008-9): “there is no recommended restriction of student athletes merely because they are infected with HIV. “

Mandatory HIV Testing

The institution shall not require mandatory HIV testing of student athletes simply for the purpose of determining clearance to participate in their sport. Rather, student athletes who practice high risk behaviors, such as IV drug use or who have multiple sexual partners and unprotected sex, shall be encouraged to be tested and know their HIV status since medical treatments are continuing to improve for HIV positive patients.

Other Infectious Diseases

Infectious disease transmission, beyond those transmitted by blood as described in 1.0 above, are a part of life. It is up to the athlete, the athletic trainers and/or the team or student health physician to decide if an athlete with an infectious disease (1) is too ill to play or (2) poses an unacceptable risk of transmission of the disease to others. The athletic trainers and/or the team/student-health physician, in discussion with the athlete, shall make the final determination on these issues.

Skin Conditions

There are certain infectious diseases, particularly certain skin conditions, which shall preclude the athlete in close-contact sports from participation, consistent with NCAA established guidelines (Sports Medicine Handbook- 2008-2009). These categories of skin conditions include, but may not be limited to: 

• Bacterial infections: such as impetigo, erysipelas, carbuncle, folliculitis, staphylococcal disease including MRSA infections
• Viral Infections: such as herpes infection and molluscum 
• Fungal Infections: such as tinea corporis
• Parasitic Infections: such as scabies 

The Institution shall ensure that infected athletes in close contact sports are properly identified by a knowledgeable individual (AT or other health care personnel) and properly treated to prevent further spread of these skin conditions.

Methicillin Resistant Staphylococcus Aureus (MRSA)

MRSA infections have become a particular concern in the general population and have increased in incidence in the athletic population. MRSA commonly causes skin infections that are resistant to many types of antibiotics. If not treated properly, MRSA can potentially cause more serious systemic infections. Therefore, appropriate antibiotics need to be used in the treatment of this potentially serious skin infection. MRSA is spread from person to person or through contact with shared items or surfaces that have touched a person’s infection. Prevention of spread is critical so as not to cause local outbreaks. MRSA can stay on surfaces for weeks; therefore surfaces need to be properly cleaned on a daily basis.   If MRSA infection is identified in a student-athlete, the Institution shall notify proper health authorities and take immediate and aggressive action to initiate decontamination procedures.

Obligation to Report Skin Infections

Athletes must report all potential skin infections to their coaches who must then have the athlete evaluated before return to play. Athletes will be excluded from play if wounds cannot be properly covered during participation. The athletic trainers and/or team physician shall make the final determination on return to play.

Standard Precautions

CMSSMP shall adhere to the following recommendations, termed “Standard Precautions”, designed to further minimize the risk of transmission of infectious organisms. CMSSMP shall be responsible for training both care-givers and others (e.g. coaches) who will be in direct contact with athletes, in the implementation of these guidelines.  Standard Precautions applies to blood, body fluids, secretions and excretions except sweat, regardless of whether or not they contain blood.

Immediate and Aggressive Treatment

Open wounds or skin lesions that have the potential risk of transmission of disease shall be immediately and aggressively treated. The athlete should be removed from competition and the bleeding controlled and the wound covered sufficiently to keep others from exposure should the athlete be allowed to return to competition.

Decision to Return to Play

The decision to return to a practice or game will be made by the certified athletic trainer or other health care personnel and/or sports officials.

Minor Cuts and Abrasions

Minor cuts or abrasions do not require interruption of play or removal of the participant from competition. These injuries should be cared for at scheduled breaks in play, such as time outs. The Institution shall adhere to guidelines as published in the most current issue of the NCAA Sports Medicine Handbook.  

Necessary Equipment and Supplies

CMSSMP shall supply necessary equipment and supplies to comply with Standard Precautions. This equipment should include vinyl gloves, disinfectant, bleach (diluted 1:100 with water), antiseptic, bandages/dressings, and appropriate receptacles for soiled equipment/clothing/needles/syringes/ scalpels as outlined in the most current issue of the NCAA Sports Medicine Handbook. 

Proper Personnel Training

CMSSMP shall ensure that personnel are trained in the proper cleaning of a contaminated environment according to OSHA Standards for Blood- Borne Pathogens and guidelines contained in the most current issue of the NCAA Sports Medicine Handbook These guidelines mandate the use of disposable gloves. The environment should be sprayed with the proper germicide and wiped clean. The contaminated items which may include clothing, along with the contaminated gloves, should be properly disposed of in waste receptacles according to facility protocol.

Personal Hygiene Items

Athletes shall be reminded not to share personal hygiene items, clothing, or water bottles, and to shower with soap and water immediately after participation in their sports.

HBV Vaccination

An effective vaccine exists to prevent HBV infection. This vaccine is recommended for all college students by the American College Health Association (ACHA) and shall be provided by the Institution to all student-athletes, coaches and other staff member who have the potential of coming into contact with bleeding individuals.

Management Strategies Regarding Dehydration, Heat- and Cold- Related Illnesses

CMS has an inclement weather policy that includes provisions for decision-making with regards to events such as lightning, heat/cold and air-quality concerns. The CMSSMP staff is empowered with the unchallengeable authority to cancel or modify a work-out or event for health and safety reasons

General

All coaches and student-athletes shall receive a copy of the current NCAA Sports Medicine Handbook guidelines on (a) weight loss and hydration, (b) prevention of heat illness, and (c) cold stress and cold exposure upon which this policy is partially based (NCAA Sports Medicine Handbook, 2014-2015).  These NCAA guidelines and this policy shall be reviewed with each team by a member of the athletics training staff prior to the start of the sport season.

Dehydration

General Policy

Dehydration can compromise athletic performance and increase the risk of exertional heat injury. Various studies have shown that (a) athletes do not voluntarily drink sufficient water to prevent dehydration during physical activity, (b) education, increasing accessibility, and optimizing palatability can modify drinking behavior, and (c) excessive overdrinking should be avoided because it can also compromise physical performance and health (Armstrong et al, 1995; Casa & Hillman, 2000; Joy, 2002; Sadler, 2006). The CMS Athletics Department has adopted practical recommendations from nationally certified associations (Inter-Agency Task Force, 2003) which were derived from research regarding fluid replacement for student-athletes to lessen the risk and prevent the likelihood of dehydration. These policies and procedures for risk prevention require a cooperative effort of educated student-athletes, coaches, and athletic training staff to ensure the safety of student-athletes.  The prevention procedures presented herein are non-negotiable and the disregard for the prevention of dehydration may result in termination of employment.

Description & Symptoms

All athletics department staff members working with student-athletes are responsible for knowing the symptoms of dehydration:  thirst, irritability, and general discomfort followed by headache, weakness, dizziness, cramps, chills, vomiting, nausea, head or neck heat sensations, and/or decreased performance.

Risk Factors

All athletics department staff members working with student-athletes are responsible for recognizing the following risk factors for heat illnesses:  extreme heat and/or humidity, excessive perspiration, inadequate fluid intake, bouts of vomiting or diarrhea prior to exercise, dark-colored urine, use of medications that are dehydrating, alcohol consumption, and caffeine use.  Particular attention should be given to barriers to evaporation: when certain types of athletic equipment do not allow water vapor to pass through and inhibit evaporative, convective, and radiant heat loss or when athletic apparel is dark-colored, causing greater absorption of heat from the environment.   Student- athletes also at increased risk are those who are currently or were recently ill, have a history of heat illness, have high body mass, are muscle-bound, are untrained or overzealous and are not yet acclimated to hot conditions.

Required Preventive Measures

Hydration Protocols

The CMSSMP staff will communicate and coordinate with coaches frequently and closely to implement a hydration protocol of risk prevention for dehydration that includes the following considerations:

• Sport dynamics (i.e. rest breaks, fluid access)
• Environmental factors
• Acclimatization state of participants
• Exercise duration
• Exercise intensity
• Individual preferences

The hydration protocol considers each sport’s unique features.  If rehydration opportunities are frequent (i.e. baseball, football, track and field), the student-athlete can consume smaller volumes at a convenient pace based on sweat rate and environmental conditions. If rehydration must occur at specific times (i.e. soccer, lacrosse, distance running), the student-athlete must consume fluids to maximize hydration within the sports rules.

Individual Protocols for High Risk Athletes

Individual hydration protocols shall be developed each season for student-athletes who have a history of heat related illness or other illness that could exacerbate dehydration, taking medications that exacerbate dehydration, those who need further acclimatization, and those who may be in poor physical condition compared to the majority of the team. These student-athletes are to be monitored closely during all practices and competitions by coaches and training staff

Athlete Education

The CMSSMP shall educate student-athletes on the effects of dehydration and the factors for risk in health and awareness sessions implemented by coaches and training staff.

Information Posters

The CMSSMP staff shall display informational posters at practice facilities and in training/locker rooms to enhance awareness

Basic Responsibilities

Coaches and sports medicine staff shall implement the hydration protocol during all practices and games, and adapt it as needed depending on environmental conditions and training or competitive intensity. Further, the athletics department, its coaches, and certified athletic training staff shall inform student-athletes on how to monitor hydration status and assist in hydration efforts by:

• A scale is available to assist student-athletes in self-monitoring weight before, during, and after activity.
• Student-athletes are informed that two pound weight loss represents approximately one quart of fluid loss and for activity up to two hours in duration, most weight loss represents water loss, and that fluid loss should be replaced as soon as possible
• Encouraging student-athletes to drink as much and as frequently as comfort allows
• Encouraging student-athletes to drink one to two eight ounce glasses of water in the hour before practice or competition, and continue drinking during activity at intervals of every fifteen to twenty minutes
• Encouraging that after activity, the student-athlete will rehydrate with a volume that exceeds the amount lost during the activity
• Fluids for the hydration of student-athletes must be provided before, during, and after exercise.
• Fluids are readily available, easily accessible, and the consumption promoted
• When extreme temperatures are present, promotion of fluid intake for student-athletes assumes the highest priority for CMSSMP staff and coaches.  The impact of such weather conditions and the importance of fluid intake shall be communicated by the coaches and sports medicine staff to student-athletes prior to the start of practices and competitions in such environments.

Practice and Competition Scheduling

The athletics department, coaches and CMSSMP staff will encourage event scheduling and rule modifications to minimize the risks associated with exercise in the heat. Practice times, frequency, and duration of practices should reflect acknowledgement of extreme heat or cold to reduce the risk of dehydration.

Equipment and Apparel Considerations

Clothing to be worn at practice and competition in extreme heat conditions shall be provided by the athletics department and meet the following criteria:

• The color and fabric of that clothing will be lighter
• Lighter apparel use shall be required by coaches and sports medicine staff to mitigate the risk of dehydration
• Sports equipment normally worn at practice (i.e., pads, long trousers, etc.) shall not be worn and the scope of practice sessions adjusted accordingly

Heat-Related Illness

General Policy

 Heat-related illness risk is inherent to physical activity and its incidence increases with rising ambient temperature and relative humidity. Student-athletes who begin training in the late summer experience exertional heat-related illness more often than student-athletes who begin training during the winter and spring. The CMSSMP policy is based on NCAA guidelines (NCAA Sports Medicine Handbook, 2014-2015) recommendations from nationally certified associations based on research and recommendations by others regarding identification of symptoms and procedures to lessen the risk and prevent the likelihood of heat-related illness occurring among student-athletes (Armstrong et al, 1995; Binkley et al, 2002; Casa and Hillman, 2000; Inter-Agency Task Force, 2003; Joy, 2002; Sadler, 2006). These policies and procedures for risk prevention require a cooperative effort of educated student-athletes, coaches, and sports medicine staff to ensure the safety of student-athletes.  The prevention procedures presented herein are non-negotiable and the disregard for the prevention of heat-related illness may result in termination of employment

Descriptions and Symptoms

Exercise-Associated Muscle (Heat) Cramps

Exercise-associated muscle cramps (i.e., acute, painful, involuntary muscle contractions) occur during or after intense exercise sessions and moderate exercise in conditions of high heat and humidity. Other systems include dehydration, thirst, sweating, and fatigue.  Cramps are caused by fluid deficiencies (dehydration), electrolyte imbalances, neuromuscular fatigue, or any combination of these factors.  Normal hydration status is established by replacing some sodium loss with a sports drink or other sodium source.  Muscles should be lightly stretched and massaged in response to pain.

Heat Syncope

Heat syncope, or orthostatic dizziness, occurs when the student-athlete is exposed to high environmental temperatures. Other symptom include dehydration, fatigue, tunnel vision, pale or sweaty skin, decreased pulse rate, dizziness, lightheadedness, fainting.  This condition results from peripheral vasodilation, postural pooling of blood, diminished venous return, dehydration, reduction in cardiac output, and/or cerebral ischemia.   Heat syncope often occurs during the first five days of preseason training as the student-athlete is acclimatizing to high heat environments.   It often occurs after standing for long periods of time, immediately after cessation of activity, or after rapid assumption of upright posture after resting or being seated.  Clothing should be removed, the student-athlete should be given a tepid sponge bath, allowed to rest in cool/shaded environment, rehydrated orally with fluids, and monitored with regard to cardiac functioning.

Exercise (Heat) Exhaustion

Exercise (heat) exhaustion is the inability to continue exercise in hot and often humid conditions usually resulting from a combination of heavy sweating, dehydration, sodium loss, and energy depletion.   Body core temperature may be normal or elevated but other symptoms may include dehydration, dizziness, lightheadedness, headache, nausea, disinterest in eating, diarrhea, decreased urine output, persistent muscle cramps, pallor, profuse sweating, chills, cool, clammy skin, intestinal cramps, urge to defecate, weakness, and hyperventilation.  It is difficult to distinguish from exertional heat stroke without measuring rectal temperature.  Clothing should be removed and the student-athlete should be given a cool sponge bath or ice bath, directed to rest in cool/shaded environment, rehydrated orally with fluids and monitored with regard to cardiac functioning.  Emergency medical assistance should be summoned if symptoms are severe.

Exertional Heat Stroke

Exertional heat stroke is an elevated core temperature (usually 40°C [104°F]) with signs of organ system failure due to hyperthermia. Symptoms include high body-core temperature (40°C [104°F]), central nervous system changes, dizziness, drowsiness, irrational behavior, confusion, irritability, emotional instability, hysteria, apathy, aggressiveness, delirium, disorientation, staggering, seizures, loss of consciousness, coma, dehydration, weakness, hot and wet or dry skin, tachycardia (100 to 120 beats per minute), hypotension, hyperventilation, vomiting, and diarrhea.  The central nervous system neurologic changes (disorientation) are often the first marker of exertional heat stroke.  This condition is life threatening and can be fatal unless promptly recognized and treated.   The risk of morbidity and mortality is significantly reduced if body temperature is lowered rapidly.  The student-athlete should be immediately immersed in an ice bath, placed in cool and shaded environment, and rehydrated orally with fluids.  Emergency transportation should be arranged if symptoms are severe but only after rapid cooling efforts.

Exertional Hyponatremia

Exertional hyponatremia is a relatively rare low serum-sodium condition that usually occurs when activity exceeds four hours, a student-athlete ingests water or low-solute beverages well beyond sweat losses (also known as water intoxication), and/or a student-athlete’s sweat sodium losses are not adequately replaced.   The resulting intracellular swelling can cause potentially fatal neurologic and physiologic dysfunction.  Other symptoms may include body-core temperature, 40°C (104°F), nausea, vomiting, extremity (hands and feet) swelling, low blood-sodium level, progressive headache, confusion, significant mental compromise, lethargy, altered consciousness, apathy, pulmonary edema, cerebral edema, seizures, and coma.  This condition can be prevented by matching fluid intake with sweat and urine losses and by rehydrating with fluids that contain sufficient sodium.   Athletics training staff in consultation with team physician arranges for intravenous rehydration with fluids containing sufficient sodium and emergency care if necessary.

Risk Factors  

All athletics department staff members working with student-athletes are responsible for recognizing the following risk factors for heat illnesses:  extreme heat and/or humidity, excessive perspiration, inadequate fluid intake, bouts of vomiting or diarrhea prior to exercise, dark-colored urine, use of medications that are dehydrating, alcohol consumption, and caffeine use.  Particular attention should be given to barriers to evaporation: when certain types of athletic equipment do not allow water vapor to pass through and inhibit evaporative, convective, and radiant heat loss or when athletic apparel is dark-colored, causing greater absorption of heat from the environment.   Student- athletes also at increased risk are those who are currently or were recently ill, have a history of heat illness, have high body mass, are muscle-bound, are untrained or overzealous and are not yet acclimated to hot conditions. 

Preventive Measures

Hydration Protocol

The CMSSMP staff and coaches will communicate frequently and closely to implement a hydration protocol of risk prevention for dehydration as outlined in sections 2.4 above.  

Preparation for Medical Care

The Head Athletic Trainer shall ensure that appropriate medical care is available and that rescue personnel are familiar with exertional heat illness prevention, recognition, and treatment.

Evaluation by Health Care Providers 

Coaches shall ensure that athletic trainers and other health care providers attending practices or events are allowed to evaluate and examine any student-athlete who displays signs or symptoms of heat illness and have the authority to restrict the student-athlete from participating if heat illness is present.

Pre-Participation Screening Requirement

The pre-participation medical screening before the season starts shall include a review of injury/illness records, medical history, and physical examination queries that identify student-athletes predisposed to heat illness on the basis of risk factors and those who have a history of exertional heat illness.

Heat Adaptation

Coaches, sports medicine staff, and strength and conditioning staff shall ensure the adoption of conditioning programs that permits student-athletes to gradually adapt to exercise in the heat (acclimatization) over ten to fourteen days. 

Education

The athletics department, sports medicine staff, and strength and conditioning staff shall educate student-athletes and coaches on an ongoing basis regarding the prevention, recognition, and treatment of heat illnesses and the risks associated with exercising in hot, humid environmental conditions.

Guidelines

The athletics department, coaches, and sports medicine staff shall develop event and practice guidelines for hot, humid weather that anticipate potential problems encountered.

Rest Breaks

Coaches and certified sports medicine staff shall plan rest breaks to match the environmental conditions and the intensity of the activity.

High Risk Student-Athletes

Sports medicine staff will weigh high-risk student-athletes, and in high-risk conditions all student-athletes, before and after practice to estimate the amount of body water lost during practice and to ensure a return to pre-practice weight before the next practice.

Clothing Adjustments

The athletics department, coaches, and sports medicine staff will minimize the amount of equipment and clothing worn by the athlete in hot or humid (or both) conditions.

Warm-Up Considerations

Coaches will minimize warm-up time when feasible, and conduct warm-up sessions in the shade when possible to minimize the radiant heat exposure for student-athletes.

Adaptation Considerations

Coaches will allow student-athletes to practice in shaded areas and use electric or cooling fans to circulate air whenever feasible.

Emergency Preparedness

The athletics department and sports medicine staff will have available for use the following supplies on the field, in the locker room, and at various other stations:

• A supply of cool water or sports drinks or both to meet the needs of student-athletes
• Ice for active cooling (ice bags, tub cooling) and to keep beverages cool during exercise
• Telephone or two-way radio to communicate with medical personnel and to summon emergency medical transportation if necessary
• Ice bath, tub to cool the trunk and extremities for immersion cooling therapy

Cold-Related Illnesses

General

Cold-related illness is inherent to physical activity outdoors and its incidence increases with dropping temperatures and in environments with wet or windy conditions (or a combination of these).  All of these factors increase the risk of cold-related injury for student-athletes. Sports like football, baseball, softball, soccer, lacrosse and track and field that have seasons extending into late fall or early winter or begin in early spring, when weather holds the potential for the aforementioned conditions increase student-athletes’ susceptibility to cold injury.  The CMS Athletics Department policy is based on NCAA guidelines recommendations from nationally certified associations, research and recommendations by others regarding identification of symptoms and procedures to lessen the risk and prevent the likelihood of cold-related illness occurring among its student-athletes (Armstrong et al, 1995; DeFranco et al, 2008; NCAA Sports Medicine Handbook, 2011; UIL, 1999).  These policies and procedures for risk prevention require a cooperative effort of coaches and sports medicine staff working together to enhance the safety of student-athletes. The prevention factors discussed herein are non-negotiable and disregard for the prevention of cold-related illness may result in termination of employment.

Descriptions & Symptoms

Hypothermia

The signs and symptoms of mild hypothermia include vigorous shivering, increased blood pressure, core body temperature less than 98.6°F(37.6°C) but greater than 95.6°F (35.6°C), fine motor skill impairment, lethargy, apathy and mild amnesia. Signs of moderate and severe hypothermia include cessation of shivering, very cold skin, depressed vital signs, core body temperature between 90.6°F (32.6°C) and 95.6°F (35.6°C) for moderate hypothermia or below 90.6°F (32.6°C) for severe hypothermia, impaired mental function, slurred speech, unconsciousness and gross motor skill impairment.

Frostbite

The signs and symptoms of superficial frostbite include swelling, redness or mottled gray skin appearance, stiffness and transient tingling or burning. Deep frostbite includes edema, mottled or gray skin appearance, tissue that feels hard and does not rebound blisters, and numbness or loss of sensation.

Chilblain

Occurs with exposure to cold, wet conditions for more than sixty minutes at temperatures less than 50.6°F (16.6°C). It can be identified by the presence of small red bumps, swelling, tenderness, itching and pain.

Immersion Foot

Immersion (Trench) Foot: Occurs with exposure to cold, wet environments for twelve hours to three or four days. Symptoms include burning, tingling or itching, loss of sensation, bluish or blotchy skin, swelling, pain or sensitivity, blisters and skin fissures or maceration.

Risk Factors

All coaches and sports medicine staff shall be educated to recognize the risk factors of cold-related illness, as listed below:

• Extreme cold, precipitation, wind
• Existing medical conditions
• Previous cold injuries increases the chance of subsequent cold injuries two to four times, even if prior injuries were not debilitating or resolved with no or minimal medical care
• Low caloric intake, dehydration, and fatigue
• Low caloric intake (less than 1200 to 1500 kcal/day) or hypoglycemia (or both) 
• Fatigue associated with hypoglycemia is linked to impaired peripheral vasoconstriction and shivering responses and can lead to faulty decision making and inadequate preparations, indirectly resulting in cold injuries
• Black individuals have been shown to be two to four times more likely than individuals from other racial groups to sustain cold injuries. These differences may be due to cold weather experience, but are likely due to anthropometric and body composition differences.
• Nicotine, alcohol, and drug use
• Low body fat and muscle mass 
• Gender. The hypothermia injury rate for females is two times higher than for males. Sex differences in thermoregulatory responses during cold exposure are influenced by interactions among total body fat content, subcutaneous fat thickness, amount of muscle mass, and surface area-to-mass ratio.
• Insufficient clothing or clothing that does not reduce heat loss.

Preventive Measures

Availability of Medical Personnel

The Head Athletic Trainer shall ensure that appropriate medical care is available and that rescue personnel are familiar with cold-related illness prevention, recognition, and treatment.

Evaluation by Health Care Provider

Coaches shall ensure that athletic trainers and other health care providers attending practices or events are allowed to evaluate and examine any student-athlete who displays signs or symptoms of cold-related illness and have the authority to restrict the student-athlete from participating if cold illness is present.

Pre-Participation Screening

The Team Physician and Head Athletic Trainer shall ensure that all student-athletes receive a thorough, physician-supervised, pre-participation medical screening before the season starts to identify student-athletes predisposed to cold-related illness on the basis of risk factors and those who have a history of cold-related illness.

Education

The Team Physician and Head Athletic Trainer shall conduct educational sessions for student-athletes and coaches concerning the prevention, recognition, and treatment of cold injury and the risks associated with activity in cold environments.

Hydration and Nutrition

 The athletics department, coaches, and sports medicine staff will educate and encourage student-athletes to maintain proper hydration and eat a well-balanced diet. These guidelines are especially imperative for activities exceeding two hours. Consistent fluid intake during low-intensity exercise is necessary and student-athletes should be encouraged to hydrate even if they are not thirsty, as evidence suggests the normal thirst mechanism is blunted with cold exposure.

Training Guidelines

The Team Physician and Head Athletic Trainer shall develop event and practice guidelines that include recommendations for managing student-athletes participating in cold, windy, and wet conditions. The influence of air temperature and wind speed conditions shall be taken into account by the use wind-chill guidelines contained in the NCAA Sports Medicine Handbook.

Clothing

Coaches are responsible for purchasing and issuing to student-athletes cold-weather clothing that provides an internal layer that allows evaporation of sweat with minimal absorption, a middle layer that provides insulation, and a removable external layer that is wind and water resistant and allows for evaporation of moisture.

Warm-Up 

Coaches shall provide the opportunity for athletes to warm-up or re-warm, as needed, during and after activity using external heaters, a warm indoor environment, or the addition of clothing.

Emergency Supplies

The athletics department and sports medicine staff will include the following supplies on the field, in the locker room, or at convenient aid stations for re-warming purposes:

• A supply of water or sports drinks for rehydration purposes as well as warm fluids for possible re-warming purposes.
• Heat packs, blankets, additional clothing, and external heaters, if feasible, for active re-warming.
• Telephone or two-way radio to communicate with additional medical personnel and to summon emergency medical transportation.
• Tub, wading pool, or whirlpool for immersion warming treatments 

Lightning/Air Quality Considerations

Lightning Safety Plan

Lightning is the most consistent and significant weather hazard for intercollegiate athletics.

General Policy

There are 60-70 fatalities and 10 times as many injuries from lighting strikes every year in the U.S. The following steps are recommended by the NCAA and NOAA to mitigate lightning hazard (NCAA Guideline 1d-Lightning Safety, July 1997-revised June 2007):

• Monitor local weather reports each day-especially when conditions are right for potential thunderstorms 
  • “Watch” means conditions are favorable for severe weather to develop.
  • “Warning” means that severe weather has been reported in an area.
  • Lightning advisory-lightning has been detected within 15 miles.
  • Lightning warning-lightning has been detected with 8 miles.
  • All clear messages (for both warnings and advisories) when the storm has moved out of the target radius.
• Know where the closest “safer structure or location” is to the field or playing area. A safer structure/location includes:
  • Any building normally occupied or used by people (e.g. a building with plumbing and/or electrical wiring that acts as a ground to lightning). Avoid using the shower/plumbing facilities and contact with electrical appliances during a thunderstorm.
  • Any vehicle with a hard metal roof (does not include a convertible or golf cart), with the windows shut. (Note: The hard metal frame and roof, not the rubber tires, protect the occupants by dissipating lightning around the vehicle and not through the occupants.
• Identify dangerous locations:
  • Small covered shelters (pools, dugouts, covered shelters, golf shelters, and picnic shelters-unless they have been properly grounded for lightning). They may actually increase the risk of lightning injury.
  • Areas connected to or near light poles, towers, and fences.
  • Any location that makes the person the highest point in the area.
• If you hear thunder, begin preparation for evacuation. When you receive a warning alert, suspend activities and head for your designated safer locations.
• If you see lightning, consider suspending activities and heading for your designated safer locations. Count the number of seconds from when you see lightning until you hear thunder, and then divide by 5 to calculate the distance in miles. Specific lightning guidelines (NLSI, NCAA and NOAA) include:
  • By the time the monitor observes 30 seconds between seeing the lightning flash and hearing its associated thunder (the storm is approximately 6 miles away), all individuals should have left the athletics site and reached a safer structure or location (note that thunder may be hard to hear during an event).
  • Blue sky and absence of rain are not guarantees that lightning will not strike (at least 10 percent of lightning occurs when there is no rainfall and there is some blue sky). Lightning can strike as much as 10 miles away from the rain shaft.
  • Do not use landline telephones-cell phones and cordless phones are safe as long as they are not connected to power.
• To resume activities wait 30 minutes after the last sound of thunder and last flash of light before resuming athletic activities
• People who have been struck by lightning do not carry an electrical charge. If a lightning strike victim shows signs of cardiac or respiratory arrest:
  • Activate the Emergency Action Plan
  • If possible, move an injured person to a safer structure or location

Air-Quality Safety Plan

Chain of Command

The decision to terminate an athletic activity in the event of poor air quality will be made by sports medicine staff present or the institutional game administrator present at a game or practice in consultation with institutional Intercollegiate Athletics Facilities & Operations staff, institutional Sports Medicine personnel, and/or game official(s) / umpire(s). These personnel shall make decisions based on the use of the Air Quality Index (AQI) chart and the Southern California Intercollegiate Athletics Conference (SCIAC) policy.

Criteria for Cancellation / Postponement of NCAA or SCIAC Activities Due to Poor Air Quality

The policy of the Southern California Intercollegiate Athletic Conference will be as follows:

• Institutional Sports Medicine personnel will inform the visiting team’s athletic trainer and/or coach and game official(s) / umpire(s) of the SCIAC policy with regards to poor air quality during pre-game warm- ups.
• Institutional Sports Medicine personnel and/or Operations and Facilities personnel will monitor one or more of the following for up to date Air Quality Index (AQI) readings and statistics.
• National Weather Service and/or National Oceanic & Atmospheric Administration (NOAA) local weather radar; and/or
• The Departments of Intercollegiate Athletics for the SCIAC Institutions will utilize the following table with regards to the Air Quality Index and recommendations for activity restrictions.

Institutional Sports Medicine personnel and/or Institutional Operations and Facilities personnel will continually update the following people with regards to the air quality and recommendations for outside activity.

• Institutional Intercollegiate Athletics administration
• Institutional head coaches and/or their designee(s)
• Institutional Strength and conditioning personnel
• Institutional Operations and Facilities personnel
• Game officials / umpires (if applicable)
• Visiting Team Head Coach and Athletic Trainer (if applicable)

If the Institutional administration has cancelled classes at the college/university due to poor air quality, the SCIAC strongly recommends the cancellation of all games, practices, and other activities. All individuals have the right to leave a site or activity, without fear of repercussion or penalty, in order to seek a safe structure or location if they feel that they are in danger from a poor air quality and/or severe weather.

The Air Quality Index (AQI)

The Air Quality Index (AQI) is an index for reporting daily air quality. It tells you how clean or polluted your outdoor air is, and what associated health effects might be a concern for you. The AQI focuses on health affects you may experience within a few hours or days after breathing polluted air. The Environmental Protection Agency (EPA) calculates the AQI for five major air pollutants regulated by the Clean Air Act: ground- level ozone, particle pollution (also known as particulate matter), carbon monoxide, sulfur dioxide, and nitrogen dioxide. For each of these pollutants, EPA has established national air quality standards to protect public health. For Information regarding indoor air quality please visit EPA’s Indoor Air Quality Website.

How the Air Quality Index (AQI) Works

Think of the AQI as a yardstick that runs from 0 to 500. The higher the AQI value, the greater the level of air pollution and the greater the health concern. For example, an AQI value of 50 represents good air quality with little potential to affect public health, while an AQI value over 200 represents very unhealthy air quality. An AQI value of 100 generally corresponds to the national air quality standard for the pollutant, which is the level EPA, has set to protect public health. AQI values below 100 are generally thought of as 100, air quality is considered to be unhealthy, at first, for certain sensitive groups of people, then for everyone as AQI values get higher.

Management Strategies Regarding Type I Diabetes

CMSSMP has adapted its’s Policies and Procedures for the Management of the athlete with type 1 diabetes from the NATA Position Statement presented in the Journal of Athletic Training 2007;42(4):536-545.
Effective management of glycemic, lipid, and blood pressure control plays an important role in the health outcomes of persons with diabetes mellitus. The primary goal of diabetes management is to consistently maintain blood glucose levels in a normal or near-normal range without provoking undue hypoglycemia.  Although several exercise guidelines for persons with diabetes have been published (American Diabetes Association’s ”Physical Activity/Exercise and Type 2 Diabetes,” American College of Sports Medicine’s ”Exercise and Type 2 Diabetes,” and the joint statement of the American College of Sports Medicine and the American Diabetes Association, ”Diabetes Mellitus and Exercise”), none address issues of concern for athletic trainers (e.g., blood glucose management strategies during injury or the effect of therapeutic modalities on blood glucose control). The following position statement and recommendations provide relevant information on type 1 diabetes mellitus and specific recommendations for athletic trainers who work with patients with diabetes.
RECOMMENDATIONS: Based on current research and literature, the National Athletic Trainers’ Association (NATA) suggests the following guidelines for management of athletes with type 1 diabetes mellitus. These recommendations have been organized into the following categories: diabetes care plan; supplies for athletic training kits; pre-participation physical examination (PPE); recognition, treatment, and prevention of hypoglycemia; recognition, treatment, and prevention of hyperglycemia; insulin administration; travel recommendations; and athletic injury and glycemic control.

Diabetes Care Plan

Each athlete with diabetes should have a diabetes care plan for practices and games. The plan should include the following:

• Blood glucose monitoring guidelines. Address frequency of monitoring and pre-exercise exclusion values.
• Insulin therapy guidelines. Should include the type of insulin used, dosages and adjustment strategies for planned activities types, as well as insulin correction dosages for high blood glucose levels.
• List of other medications. Include those used to assist with glycemic control and/or to treat other diabetes related conditions.
• Guidelines for hypoglycemia recognition and treatment. Include prevention, signs, symptoms, and treatment of hypoglycemia, including instructions on the use of glucagon.
• Guidelines for hyperglycemia recognition and treatment. Include prevention, signs, symptoms, and treatment of hyperglycemia and ketosis.
• Emergency contact information. Include parents’ and/ or other family member’s telephone numbers, physician’s telephone number, and consent for medical treatment (for minors).
• Athletes with diabetes should have a medic alert tag with them at all times.

Supplies for Athletic Training Kits

Supplies to treat diabetes-related emergencies should be available at all practices and games. The athlete (or athlete’s parents/guardians, in the case of minors) shall provide the following items:

• A copy of the diabetes care plan.
• Blood glucose monitoring equipment and supplies. The athletic trainer should check the expiration dates of supplies, such as blood glucose testing strips and insulin, on a regular basis. Blood glucose testing strips have a code number located on the outside of the test strip vial. The code number on the blood glucose meter and test strip vial must match.
• Supplies to treat hypoglycemia, including sugary foods (e.g., glucose tablets, sugar packets) or sugary fluids (e.g., orange juice, non-diet soda) and a glucagon injection kit.
• Supplies for urine or blood ketone testing.
• A ”sharps” container to ensure proper disposal of syringes and lancets.
• Spare batteries (for blood glucose meter and/or insulin pump) and, if applicable, spare infusion sets and reservoirs for insulin pumps.

Preparticipation Physical Examination

Athletes with type 1 diabetes should have a glycosylated hemoglobin (HbA1c) assay every 3 to 4 months to assess overall long-term glycemic control. However, the HbA1c value is not used to make day-to-day decisions concerning participation. An annual examination for retinopathy, nephropathy, and neuropathy is recommended along with an annual foot examination to check sensory function and ankle reflexes. Screening for cardiovascular disease should occur at intervals recommended by the athlete’s endocrinologist or cardiologist. Exercise limitations or restrictions for athletes with diabetes-related complications should be determined by the athlete’s physician.

Recognition, Treatment, and Prevention of Hypoglycemia

Strategies to recognize, treat, and prevent hypoglycemia typically include blood glucose monitoring, carbohydrate supplementation, and/or insulin adjustments. Athletes with diabetes should discuss with their physicians specific carbohydrate qualities and quantities as well as the use of an insulin reduction plan for activity. Athletic trainers should know the signs, symptoms, and treatment guidelines for mild and severe hypoglycemia. Hypoglycemia is defined as mild if the athlete is conscious and able to swallow and follow directions or severe if the athletes is unable to swallow, follow directions, or eat as directed or is unconscious. Treatment of severe hypoglycemia requires a glucagon injection, and athletic trainers should be trained in mixing and administering glucagon. The athlete, athlete’s family, or physician can provide appropriate training.

Recognition, Treatment, and Prevention of Hyperglycemia

•  Athletes with type 1 diabetes and athletic trainers are advised to follow the American Diabetes Association (ADA) guidelines for avoiding exercise during periods of hyperglycemia.
• Athletes with type 1 diabetes who experience hyperglycemia during short-term, intense, and stressful periods of exercise should consult with their physicians concerning an increased basal rate or the use of small insulin boluses to counteract this phenomenon.
• Athletes should drink noncarbohydrate fluids when blood glucose levels exceed the renal glucose threshold (180 mg/ dL, or 10 mmol/L), which may lead to increased urination, fluid loss, and dehydration.

Insulin Administration

Insulin should be administered into the subcutaneous tissue. The abdomen, upper thigh, and upper arms are common sites for injection. Intramuscular injections of insulin should always be avoided as muscle contractions may accelerate insulin absorption.
Depending on the type of insulin used by the athlete, heat and cold should be avoided for 1 to 3 hours after an injection of rapid-acting insulin (eg, lispro, aspart, or glulisine) and up to 4 hours for fast-acting (eg, regular) insulin.31,32 Heat may increase insulin absorption rates. Thus, athletes with type 1 diabetes should avoid warm whirlpools, saunas, showers, hot tubs, and baths after injection. Local heat-producing modalities such as moist hot packs, diathermy, and thermal ultrasound should not be applied directly over an infusion or injection site. By contrast, cold may decrease insulin absorption rates. Therefore, athletes with type 1 diabetes should avoid using ice and cold sprays directly over the injection or infusion site after insulin administration. Similarly, cold whirlpools should be avoided after insulin injection.
Insulin pump users should replace insulin infusion sets every 2 to 3 days to reduce skin and infusion site irritation.
Extreme ambient temperature (36F or 86F [2.2C or 30C]) can reduce insulin action. Athletes with type 1 diabetes are advised to check blood glucose levels frequently and replace the entire insulin-filled cartridge and infusion set if any signs of unusual hyperglycemia occur in extreme environmental conditions.

Travel Recommendations

Athletic trainers should review the advice provided by the Transportation Security Administration (TSA) in conjunction with the ADA for airline passengers with diabetes traveling within the United States. In addition, athletes are advised to carry diabetes supplies with them and have prescriptions available in the event that medication or supplies need to be replaced. Due to extreme temperature fluctuations that could affect insulin action, insulin should not be stored in the cargo hold of the airplane.
When traveling, athletes with type 1 diabetes are advised to carry prepackaged meals and snacks in case food availability is interrupted. If travel occurs over several time zones, insulin therapy may need to be adjusted to coordinate with changes in eating and activity patterns.

Management Strategies Regarding Asthma

Background

Many athletes have difficulty breathing during or after athletic events and practices. Although a wide variety of conditions can predispose an athlete to breathing difficulties, the most common cause is undiagnosed or uncontrolled asthma. At least 15% to 25% of athletes may have signs and symptoms suggestive of asthma, including exercise-induced asthma. Athletic trainers are in a unique position to recognize breathing difficulties caused by undiagnosed or uncontrolled asthma, particularly when asthma follows exercise. Once the diagnosis of asthma is made, the athletic trainer should play a pivotal role in supervising therapies to prevent and control asthma symptoms. It is also important for the athletic trainer to recognize when asthma is not the underlying cause for respiratory difficulties, so that the athlete can be evaluated and treated properly.

Asthma Identification and Diagnosis

All athletes must receive pre-participation screening evaluations sufficient to identify the possible presence of asthma. In most situations, this evaluation includes only obtaining a thorough history from the athlete. However, in special circumstances, additional screening evaluations (e.g., spirometry testing or the challenge testing described below) should also be performed because the history alone is not reliable. Athletic trainers should be aware of the major signs and symptoms suggesting asthma, as well as the following associated conditions:

• Chest tightness (or chest pain in children
• Coughing (especially at night)
• Prolonged shortness of breath (dyspnea)
• Difficulty sleeping
• Wheezing (especially after exercise)
• Inability to catch one’s breath
• Physical activities affected by breathing difficulty
• Use of accessory muscles to breathe
• Breathing difficulty upon awakening in the morning
• Breathing difficulty when exposed to certain allergens or irritants
• Exercise-induced symptoms, such as coughing or wheezing
• An athlete who is well conditioned but does not seem to be able to perform at a level comparable with other athletes who do not have asthma
• Family history of asthma
• Personal history of atopy, including atopic dermatitis/ eczema or hay fever (allergic rhinitis)

Note: Although there is a correlation between the presence of symptoms and EIA, the diagnosis should not be based on history alone. Rather, these symptoms should serve to suggest that an athlete may have asthma.

The following types of screening questions can be asked to seek evidence of asthma:

• Does the patient have breathing attacks consisting of coughing, wheezing, chest tightness, or shortness of breath (dyspnea)?
• Does the patient have coughing, wheezing, chest tightness, or shortness of breath (dyspnea) at night?
• Does the patient have coughing, wheezing, or chest tightness after exercise?
• Does the patient have coughing, wheezing, chest tightness, or shortness of breath (dyspnea) after exposure to allergens or pollutants?
• Which pharmacologic treatments for asthma or allergic rhinitis, if any, were given in the past, and were they successful?

Patients with atypical symptoms, symptoms despite proper therapy, or other complications that can exacerbate asthma (such as sinusitis, nasal polyps, severe rhinitis, gastroesophageal reflux disease, or vocal cord dysfunction) should be referred to a physician with expertise in sports medicine (eg, allergist; ear, nose, and throat physician; cardiologist; or pulmonologist with training in providing care for athletes). Testing might include a stress electrocardiogram, upper airway laryngoscopy or rhinoscopy, echocardiogram, or upper endoscopy.

Pulmonary Function Testing

Athletes with a history of asthma or of taking a medication used to treat asthma and those suspected of ng asthma should consult a physician for proper medical evaluation and to obtain a classification of asthma severity. This evaluation should include pulmonary function testing.

National Asthma Education and Prevention Program II: Classification of Asthma Severity

An exercise challenge test is recommended for athletes who have symptoms suggestive of EIA to confirm the diagnosis. If the diagnoses of asthma remains unclear after the above tests have been performed, then additional testing should be performed to assist in making a diagnosis. Physicians should be encouraged, when possible, to test the athlete using a sport-specific and environment-specific exercise-challenge protocol, in which the athlete participates in his or her venue to replicate the activity or activities and the environment that may serve to trigger airway hyper- responsiveness. In some cases, athletes should also be tested for metabolic gas exchange during strenuous exercise to determine fitness (eg, to assess anaerobic threshold and V̇o2max), especially to rule out the diagnosis of asthma or to rule in another diagnosis (eg, pulmonary fibrosis) for a patient with an unclear diagnosis.

Asthma Management

CMSSMP shall incorporate into the existing emergency action plan an asthma action plan for managing and urgently referring all patients who may experience significant or life-threatening attacks of breathing difficulties.  Immediate access to emergency facilities during practices and game situations shall be available. Athletic trainers should have pulmonary function measuring devices (such as peak expiratory flow meters [PFMs] or portable spirometers) at all athletic venues for athletes for whom such devices have been prescribed and should be familiar with how to use these devices.

Asthma Action Plan

Athletes who are experiencing any degree of respiratory distress (including a significant increase in wheezing or chest tightness, a respiratory rate greater than 25 breaths per minute, inability to speak in full sentences, uncontrolled cough, significantly prolonged expiration phase of breathing, nasal flaring, or paradoxic abdominal movement) should be referred rapidly to an emergency department or to their personal physicians for further evaluation and treatment. Referral to an emergency room or equivalent facility should be sought urgently if the patient is exhibiting signs of impending respiratory failure (eg, weak respiratory efforts, weak breath sounds, unconsciousness, or hypoxic seizures).
All athletes with asthma should have a rescue inhaler available during games and practices, and the certified athletic trainer should have an extra rescue inhaler for each athlete for administration during emergencies. In case of emergencies, a nebulizer should also be available. With a metered dose inhaler (MDI), athletes should be encouraged to use a spacer to help ensure the best delivery of inhaled therapy to the lungs.
Athletic trainers and coaches may consider providing alternative practice sites for athletes with asthma triggered by airborne allergens when practical. Indoor practice facilities that offer good ventilation and air conditioning should be considered for at least part of the practice if this can be accomplished, although in most cases it will not be practical. For example, indoor and outdoor allergens or irritants, tobacco smoke, and air pollutants might trigger asthma, and attempts should be made to limit exposure to these triggers when possible. Another option is to schedule practices when pollen counts are lowest (eg, in the evening during the ragweed pollen season). Pollen count information can be accessed from the National Allergy Bureau.
Patients with asthma should have follow-up examinations at regular intervals, as determined by the patient’s primary care physician or specialist, to monitor and alter therapy. In general, these evaluations should be scheduled at least every 6 to 12 months, but they may be more frequent if symptoms are not well controlled.

Asthma Pharmacologic Treatment

Athletic trainers shall understand the various types of pharmacologic strategies used for short- and long-term asthma control and should be able to differentiate controller from rescue or reliever medications

Asthma pharmacologic management. PEF indicates peak expiratory flow

Athletes with EIA may benefit from the use of short- and long-acting β2-agonists. Rapid-acting agents can be used for prophylaxis during practice and game participation. When the goal is to prevent EIA, a short-acting β2-agonist, such as albuterol, should be inhaled 10 to 15 minutes before exercise. The excessive need (3-4 times per day) for short-acting β2-agonist therapy during practice or an athletic event should cause concern, and a physician should evaluate the patient before return to participation. Long-acting β2-agonists should, in general, only be used for asthma prophylaxis and control and are usually combined with an inhaled corticosteroid. Athletic trainers should understand the use, misuse, and abuse of short-acting β2-agonists. Athletes with asthma may also benefit from the use of leukotriene modifiers, inhaled or parenteral corticosteroids, and cromones (such as cromolyn sodium). Pharmacotherapy should be customized for each asthma patient, and a specialist (an allergist or pulmonologist with expertise in sports medicine) should be consulted to maximize therapy when symptoms break through despite apparently optimal therapy. Athletes with past allergic reactions or intolerance to aspirin or NSAIDs should be identified and provided with alternative medicines, such as acetaminophen, as needed.

Asthma Nonpharmacologic Treatment

Health care providers should identify and consider nonpharmacologic strategies to control asthma, including nose breathing, limiting exposure to allergens or pollutants, and air filtration systems. However, these therapies should be expected to provide only limited protection from asthma in most circumstances. Proper warm-up before exercise may lead to a refractory period of as long as 2 hours, which may result in decreased reliance on medications by some patients with asthma. Patients who have been diagnosed previously as having asthma or suspected of having asthma should follow the recommendations of NAEPPII and GINA for evaluation and everyday management and control.

Asthma Education

Athletes shall be properly educated about asthma, especially EIA, by health care professionals who are knowledgeable about asthma.  Athletes should be educated about the following:

• Recognizing the signs and symptoms of uncontrolled asthma.
• Using spirometry recording devices to monitor lung function away from the clinic or athletic training room.
• Methods of limiting exposure to primary and secondary smoke and to other recognized or suspicious asthma triggers (e.g., pollens, animal allergens, fungi, house dust, and other asthma sensitizers and triggers). Patients with asthma who smoke should be provided with information about smoking cessation and encouraged to participate in classes to change socialization patterns.
• The need for increased asthma rescue medication (e.g., short-acting β2-agonists) as a signal for asthma flare-up. Increased use of short-acting β2-agonists signals a need for enhanced treatment with asthma controller therapy.
• The proper techniques for using MDIs, dry powder inhalers, nebulizers, and spacers to control asthma symptoms and to treat exacerbations. Health care professionals should periodically check the patient’s medication administration techniques and should examine medication compliance.
• Asthma and EIA among competitive athletes. These conditions are common, and athletic performance need not be hindered if the patient takes an active role in controlling the disease and follows good practice and control measures.

The athletic trainer should also be familiar with vocal cord dysfunction and other upper airway diseases, which can sometimes be confused with asthma. Vocal cord dysfunction may be associated with dyspnea, chest tightness, and coughing, wheezing, and inspiratory stridor. In many cases, the condition is triggered with exercise. Visual inspection of the vocal cords by a physician experienced in examining the upper airway during exercise to differentiate vocal cord dysfunction from asthma is recommended.
Patients with asthma should be encouraged to engage in exercise as a means to strengthen muscles, improve respiratory health, enhance endurance, and otherwise improve overall well-being.
The athletic trainer should differentiate among restricted, banned, and permitted asthma medications. Athletic trainers should be familiar with the guidelines of the International Olympic Committee Medical Commission, the United States Anti-Doping Agency, the World Anti-Doping Agency, and the doping committees of the various federations.
The athletic trainer should be aware of the various Web sites that provide general information and frequently asked questions on asthma and EIA. These sites include the American Academy of Allergy, Asthma and Immunology; the American Thoracic Society; the Asthma and Allergy Foundation of America; the American College of Allergy, Asthma, & Immunology; and USA Swimming.

Management Strategies Regarding Concussion Management

The Claremont-Mudd-Scripps Colleges Athletics Dept. (CMS Athletics) is committed to the safety, welfare and academic success of all CMS student-athletes. In accordance with the NCAA Executive Committee, and NCAA Concussion Policy and Legislation, CMS Sports Medicine has adapted and implemented a concussion management plan to help prevent, identify, evaluate and manage concussions sustained by our student-athletes. This protocol is approved by the CMS Team Physician and it provides contemporaneously appropriate guidelines that should be followed in the event that a CMS student-athlete suffers a concussion, whether that injury is caused by an athletic or non-athletic related activity. This plan is specific to the CMS intercollegiate athletic population. This plan will be updated annually or as needed to the most current research and best practices.

What is a Concussion?

A concussion is a change in brain function following a force to the head, which may be accompanied by temporary loss of consciousness, but is identified in awake individuals with measures of neurologic and cognitive dysfunction.

What causes a Concussion?

A concussion is caused by an acceleration, deceleration, or torsional force to the brain that results from the transmitted force of a blow to the body. While the most common mechanism is from a direct blow to the head, a concussion can also occur from a blow to another part of the body. For example, athletes have been concussed from a body-to-body or body-to-ground collision. Because of the nature of this brain injury, it is important to understand that it can occur in any sport.
The signs and symptoms of neurologic and cognitive dysfunction include:

• Headache
• Dizziness
• Ringing in the ears
• Fatigue/low energy
• Feeling emotional
• Pressure in head
• Abnormal vision
• Feeling slowed down
• Confusion
• Irritability
• Neck pain
• Balance problems
• Feeling like “in a fog”
• Drowsiness
• Sadness/depression
• Nausea
• Sensitivity to light
• Difficulty concentrating
• Trouble falling asleep
• Nervous/anxious
• Vomiting
• Sensitivity to noise
• Difficulty remembering
• Sleeping more than usual
• “Don’t feel right”

While sports concussions most commonly result in rapid onset of signs and symptoms, in some circumstances they may appear hours, or rarely, even days after the injury. Furthermore, these signs and symptoms are not unique to concussions only. For example, the athlete with a common cold may present with many of the same symptoms listed above. This makes the management of the concussed athlete that much more challenging for the healthcare provider.
Co-morbidities must be considered when working with the concussed athlete. These include diagnosis such as learning disabilities, attention deficit hyperactivity disorder (ADHD), seizure disorders, migraine headaches, or psychiatric disorders. These modifying factors present yet another challenge in the diagnosis and management of concussions.
It is important to note that there is no singular test or measure that can accurately identify a concussion. Thus, the CMSSMP Concussion Management Plan employs the use of a number of assessments along with an in-depth clinical evaluation by a physician or other qualified medical practitioner to diagnose a concussion. The information gleaned from these efforts, and from the student-athlete’s specific medical history, will be carefully considered in the design of each student-athlete’s individualized plan for care.

Concussion Management Plan

The CMSSMP Concussion Management Plan is comprised of six sections:

1. Education
2. Pre-Participation Assessment
3. Recognition, Evaluation, and Diagnosis of Concussion
4. Post-Concussion Management
5. Academic Accommodations and Return-to-Learn
6. Clearance and Return-to-Play Protocol

Education

• All CMS student-athletes are provided with a digital copy of the NCAA Concussion Fact Sheet for Student-Athletes, and are required to watch an online video provided by the NCAA on an annual basis.
• All CMS student-athletes are required to read and sign a Student-Athlete Concussion Responsibility Statement on an annual basis. In this statement, the student-athlete acknowledges that he/she has read and understands the concussion fact sheet, watched the video and has completed baseline  testing.
• All CMS coaches, administrators, and sports medicine staff are educated annually on the signs and symptoms of concussion using NCAA developed or approved educational materials and are given the opportunity to discuss and ask questions.
• All CMS coaches, administrators and sports medicine staff are also required annually to read and sign a Coach/Staff Concussion Acknowledgement Statement, in which they acknowledge that they have read and understand the concussion fact sheet and CMS Concussion Management Plan and completed the online training.

• Limiting head trauma exposure in a manner consistent with Interassociation Recommendations:

  Examples:

  All practices and competitions adhere to existing ethical standards. 

  Using playing or protective equipment (including the helmet) as a weapon is prohibited during all practices and competitions.

  In all practices and competitions, deliberately inflicting injury on another player is prohibited.

  All playing and protective equipment (including helmets), as applicable, meet relevant equipment safety standards and related certification requirements.

  All contact/collision, helmeted practices and competitions adhere to keeping the head out of blocking and tackling

Pre-Participation Assessment

• All new and returning CMS student-athletes will complete a concussion history/symptom baseline questionnaire as a part of their annual medical clearance process.
• All CMS student-athletes involved with high-risk sports will also establish baseline scores on the Standardized Assessment for Concussion (SAC), Biodex Bio Sway Balance System, and Eye Guide Vestibular tracking system or equivalent tests prior to the first sport in each season of participation for CMS. These sports include: football, soccer, basketball, water polo, lacrosse, baseball, softball, volleyball, diving, and pole vault.

• Athletes may not participate in practice or team strength & conditioning until a concussion baseline has been established.

Recognition, Evaluation, and Diagnosis of Concussion

• All student-athletes who are experiencing signs, symptoms, or behaviors consistent with a concussion, at rest or with exertion, must be removed from all athletic activity for at least the remainder of that day, and must be referred to a CMS athletic trainer or physician for evaluation.

• Medical personnel with training in the diagnosis, treatment and management of concussion will be present at all games, and available on campus for all practices involving contact sports (football, soccer, basketball, water polo, lacrosse, baseball, softball, volleyball, diving, and pole vault). Medical personnel will be available on campus or via designated emergency phone for all other sports.

• A CMS athletic trainer or physician will evaluate the student-athlete suspected of having a concussion. This initial evaluation will include any of the followingas deemed appropriate:
  • Neurological  Exam
  • Symptom  Assessment
  • Cognitive Assessment
  • Balance Assessment
  • Vestibular/Ocular Motor Assessment
  • Assessment for possible associated injuries such as neck and spine trauma, skull fracture, and intracranial bleeding.
    • For Football Only:
      • If a player’s helmet comes off during participation, the helmet will be inspected for proper fit by the football equipment staff or other qualified individual BEFORE the athlete is allowed to resume participation.
      • If a player is evaluated for concussion, and it is determined that the player may return to participation, the helmet will be inspected for proper fit by the football equipment staff or other qualified individual.
      • After treatment for concussion, and prior to return to play, the athlete’s helmet will be inspected for proper fit by the football equipment staff or other qualified individual.

CMS Traumatic Incident Guidelines Activation

Traumatic Incident Guidelines will be activated and the athlete transported to the nearest appropriate medical facility if any of the following signs or symptoms are present:

• • GCS less than 13
  • Any loss of consciousness
  • Focal neurological deficit
  • Repetitive vomiting
  • Persistently diminished or worsening mental status or other neurological signs or symptoms
  • Potential spine injury

Off Campus Travel Management

Athletes who sustain a concussion, or suspected concussion, while travelling to an away contest without a CMS Sports Medicine staff member, will be evaluated by the host medical staff and that institutions concussion management plan will be followed until care is available by the CMS staff. CMS coaches will follow all recommendations and restrictions by the host medical staff and notify the CMS medical staff via the injury management protocol as outlined.

Post-Concussion Management

All concussed student-athletes will be evaluated by the CMS team physician. The sports medicine staff will prescribe an individualized management plan for the student-athlete that may include athletic restrictions and/or academic accommodations.

• All student-athletes suspected of sustaining a concussion will be removed from all athletic activity at least for the remainder of that day, and will be evaluated as described above. The student-athlete must refrain from all athletic activity and exercise until cleared by the CMS team physician.
• Once it is determined that the student-athlete can be released from the supervision of the CMS athletic trainer, a Concussion Home Care Instructions sheet will be provided and explained to both the concussed student-athlete and a responsible adult (e.g., student affairs personnel, parent or roommate) who will continue to monitor the student-athlete.
• The Sports Medicine Department will report the injury to the Disability Services Office, Dean of Student’s Office and the Student Health Center (SHC). Cognitive rest is instrumental during the initial recovery phase, so appropriate academic accommodations may be recommended. See Academic Accommodations and Return-to-Learn below.
• Serial evaluation by a CMS athletic trainer will take place on a daily basis, unless otherwise directed by the team physician, in order to assess any deterioration of signs, symptoms, or cognitive function.   These evaluations will include at least a symptom assessment, and may include SAC and BESS scores. These scores will be compared to established baseline scores.
• CMSSMP is committed to the overall health and well-being of our student-athletes. Thus, in addition to medical treatment, concussed student-athletes may also be referred to the Monsour Counseling & Psychological Services to  meet with  a counselor. The purpose of this session is to evaluate and address the psychological effects that the injury may have had on the student-athlete. After this initial referral, both the counselor and the student-athlete can decide upon the necessity for subsequent sessions.
• In some cases, the CMS Sports Medicine staff may approve a return to light, aerobic, non-contact activity (e.g., stationary bike, elliptical) before full recovery to baseline levels has been attained.

Academic Accommodations and Return-to-Learn

• The Disability Services Office, in conjunction with the team physician and CMSSMP, will make appropriate recommendations for provisional academic accommodations to the student-athlete’s professors.
• For the student-athlete who reports moderate to severe symptoms, academic accommodations may begin with a cognitive rest and recovery period of up   to seven days post-injury. During this time, the student-athlete may be temporarily excused from classes, assignments, and exams, provided that the injury has been documented with the CMSSMP and Disability Services Office.
• The student-athlete with only mild symptoms may be allowed to continue academic participation; however, academic accommodations may be recommended depending on the types of symptoms present. See Concussion Academic Accommodations.  This Return-to-Learn clearance is contingent on the student-athletes symptom status being documented with the Sports Medicine Staff, who will in turn notify the Disability Services Office.
• Once asymptomatic, if the student-athlete experiences a recurrence of concussion symptoms, the team Physician will be notified and the reinstatement of academic accommodations will be considered.
• For those student-athletes who present with prolonged symptom and cognitive   impairment, the team physician may prescribe a neuropsychological evaluation in order to (a) determine the nature and severity of cognitive impairment, and (b) identify the extent to which psychological issues may be present and may be interacting with the cognitive processes.
• The CMSSMP staff will communicate as needed with SHS and Disability Services Office to ensure that the most current and appropriate accommodations are in place for the student-athlete. This updating process will continue until the student-athlete has made a complete return to unrestricted athletic and academic participation. The Graduated Return-To-Learn Guidance Form will be followed by the athlete verifying that they have returned to full academic standing prior to being cleared for full participation in sport.

Clearance and Return-to-Play Protocol

Once the student-athlete is asymptomatic and has returned to baseline levels (on SAC, BESS, Biodex Balance, Vestibular-Ocular-Motor-screening Test and GCS test scores), he/she may be cleared by the team physician or their designate to begin a Return-to-Play Protocol. This protocol is a stepwise progression of exercise, athletic activity, and contact risk that is supervised by the athletic trainer.

Stepwise Return-to-Play Protocol

1. Light aerobic exercise (e.g. Walking, swimming, or stationary cycling; no resistance training)
2. Mode,  duration, and intensity—dependent exercise based  upon sport
3. Sport-specific  activity with no head contact
4. Non-contact sport drills  and resumption of progressive resistance training
5. Full-contact practice
6. Return to play

Each student-athlete’s Return-to-Play Protocol will be individualized within the general outline indicated above. Special consideration will be given to the athlete’s sport, level and duration of concussive symptomology, and any present modifiers   (e.g., previous concussion, history of migraine headaches, ADHD, learning disabilities) when customizing the protocol.

Each student-athlete’s Return-to-Play Protocol will be individualized within the general outline indicated above. Special consideration will be given to the athlete’s sport, level and duration of concussive symptomology, and any present modifiers   (e.g., previous concussion, history of migraine headaches, ADHD, learning disabilities) when customizing the protocol.

It is important that the student-athlete remains symptom-stable throughout the execution of the Return-To-Play Protocol. Thus, the student-athlete will report changes in symptoms after each step and prior to the next.

If at any point, the student-athlete becomes symptomatic, or scores on clinical/cognitive measures decline, the student-athlete will be returned to the previous step of activity until symptoms resolve.

Once the Return-To-Play Protocol has been completed, and the athlete has verified that they have returned to FULL academic function, or have a written plan with their faculty, Return- To- Play testing will be conducted including at least SCAT (current version), balance assessment and vestibular/ocular assessment testing.

Final medical clearance for unrestricted return to play will be given by the Team Physician.

Athletes may be required to complete a daily symptom diary for up to 7 days following clearance.

All documentation will be submitted to Student Health Services, and office of Student Affairs for record keeping.

Concussion Academic Accommodations

Concussion Symptom List and Categories

Physical:

• Headache
• “Pressure in head”
• Neck Pain
• Nausea
• Vomiting
• Dizziness
• Blurred/Abnormal  Vision
• Balance  Problems
• Sensitivity to Light
• Sensitivity to Noise/Sound
• Tinnitus/”ringing in  the ears”

Cognitive:

• Feeling slowed down
• Feeling like “in a fog”
• Don’t feel right”
• Difficulty concentrating
• Difficulty remembering
• Confusion

Sleep/Energy:

• Fatigue or low energy
• Drowsiness
• Trouble falling asleep
• Sleeping more than usual

Emotional:

• Feeling more emotional
• Irritability
• Sadness or depression
• Nervous or anxious

Suggested Accommodations

Physical Symptoms:

• Remove from physical activity without penalty.
• Sit out of music and computer classes if symptoms are provoked.
• Allow rest breaks during class.
• Allow wearing of sunglasses, both outdoors and indoors.

Emotional Symptoms:

• Allow student to remove him/herself from class to de-escalate. Student can establish a “signal” letting the professor know that he/she is leaving the room because of escalating symptoms.
• Understand that mental fatigue can manifest in “emotional meltdowns.”
• Watch for secondary symptoms of depression and anxiety usually due to social isolation and concern over “make-up” work and slipping grades.

Sleep/Energy Symptoms:

• Allow rest breaks during class.
• Alternate “mental challenge” with “mental rest.”
• Allow student to leave class early.

Cognitive Symptoms:

• Feeling slowed down. (Area of Concern: Slowed processing speed)
  • Provide extra time for tests andassignments.
  • Adjust (postpone) due dates/test dates, especially during the first-week critical recovery period.
  • Provide a peer note-taker or additional notes, if possible.
  • Reduce the cognitive load and apply flexibility with assignments (smaller amounts of learning will need to take place during recovery).
• Difficulty concentrating, feeling like in a “fog,” “don’t feel right.” (Area of Concern: Difficulty concentrating)
  • Reduce the cognitive load and apply flexibility with assignments (smaller amounts of learning will need to take place during recovery).
  • Consider: what is the most important concept for the student to learn during this recovery?
  • Be careful not to tax the student cognitively by expecting that all learning continue at the rate prior to the concussion.
• Difficulty remembering. (Area of Concern: Difficulty with working memory)
  • Work toward comprehension of smaller amounts of material versus rote memorization.
  • Remove “busy” work that is not essential for comprehension. Making the student accountable for all work missed during the recovery period places undue cognitive and emotional strain on him/her and may   hamper recovery.
  • Consider:  what is the most important concept for the student to learn during this recovery?
• Confusion (Area of Concern: Emotional)
  • Be mindful of emotional symptoms throughout! Students are often scared, overloaded, frustrated, irritable, angry and depressed as a result of concussion. They respond well to support and reassurance that what they are feeling is often the typical course of recovery.
  • Watch for secondary symptoms of depression - usually from social isolation.
  • Watch for secondary symptoms of anxiety-usually from concerns over make-up work or slipping grades.

Management Strategies Regarding Eating Disorders

Disordered eating (DE) in athletes is characterized by a wide spectrum of maladaptive eating and weight control behaviors and attitudes. These include concerns about body weight and shape; poor nutrition or inadequate caloric intake, or both; binge eating; use of laxatives, diuretics, and diet pills; and extreme weight control methods, such as fasting, vomiting, and excessive exercise. Susceptibility of athletes to DE is a serious concern because of increased physiologic demands imposed by high-intensity and high-volume sport training. Certified athletic trainers should be mindful of their scope of practice limitations. Athletic trainers have the clinical knowledge and skills to identify signs and symptoms that indicate risk, can confront athletes with suspicious behaviors, and provide assistance as needed to facilitate timely referrals and treatment compliance. However, diagnosis and treatment can ONLY be managed by physicians and psychotherapists who specialize in DE’s. The role of the CMSSMP is as follows:

• Intervene if an athlete is suspected of having disordered eating and make appropriate referrals when warranted
• Prepare the athlete for referral and address any questions or concerns relevant to the referral
• Arrange for treatment according to the caregivers’ directives
• Maintain open lines of communication on a regular basis with and among caregivers as individual treatment plans are formulated for the patient (with strict adherence to HIPAA and FERPA guidelines)
• Ensure that all caregivers are aware of the treatment plan in its entirety
• Provide feedback to caregivers regarding the athlete’s progress relative to training and performance, interpersonal issues, academics, and family factors
• Assist in the coordination of ongoing medical surveillance plans characterized by periodic check-ups and serial health testing that helps caregivers monitor the progress of athletes and determine if treatment plans are in line with meeting their special medical needs;
• Monitor the athlete’s compliance with the treatment plan by maintaining records of scheduled appointments, noting missed appointments, and charting changes in body weight, body composition, and sport-specific measures
• Share noncompliance issues with all caregivers.
• Assume the role as liaison among coaches and caregivers in circumstances where athletics participation may have to be modified or discontinued due to energy deficits, injury, or treatment noncompliance.
• Enforce limitations of workouts based on recommendations of caregivers and intervene when training expectations are potentially dangerous or detrimental.
• Intervene in a crisis situation when the immediate welfare and safety of the athlete is in jeopardy (e.g., impending relapse, athlete is acutely suicidal) and arrange for appropriate referral.
• Field questions, concerns, observations, and criticisms from the athlete as well as coaches, teammates, parents, and close significant others (the latter group of individuals should be encouraged to share observations and concerns with the certified athletic trainer and other caregivers, being mindful of the patient’s right to privacy).
• Remain sensitive to the athlete’s preferences for staying connected with teammates in an effort to help ease the feelings of loneliness and alienation that are associated with participation restrictions.
• Adhere to disclosure regulations regarding patient confidentiality.
• Ensure that matters relative to insurance and expense coverage have been discussed and that   the financial aspects of the treatment plan are manageable for the athlete and his/her family.
• Consult with athletics administrators on issues that can complicate care, in particular, coaches and support staff who trigger or perpetuate the problems and ignore suspicious behaviors, athletes who are resistant to referral or noncompliant with the treatment process; and parents or close significant others who are uncooperative.

Disordered Eating Decision Tree  

Management Strategies Regarding Rhabdomyolysis

Modified from the NCAA Sports Medicine Handbook Guideline 2T

Rhabdomyolysis.  

Rhabdomyolysis connotes an acute clinical syndrome of major muscle breakdown and leakage of muscle contents (electrolytes, myoglobin, and other proteins) into the bloodstream. This leakage generates a sharp rise in serum creatine kinase (CK). Complications can occur due to the release of muscle contents into the bloodstream. Acute Kidney Injury (AKI) is the most common systemic complication of rhabdomyolysis. It occurs at an incidence ranging between 10 and 55%. 

Exertional Rhabdomyolysis (ER). 

Significant breakdown of muscle tissue caused by extreme physical exertion. Exact prevalence and incidence are unclear.

Delayed Onset Muscle Soreness (DOMS). 

Where muscles become sore and stiff in the first few days following a bout of unaccustomed, moderately strenuous exercise. DOMS is rarely a clinical problem and tends to be self-limited with only relative rest or a cutback in level of training.

Recognition of Exertional Rhabdomyolysis.

ER can occur during strenuous exercise and can range from mild to severe. Clinical signs are often nonspecific: muscle pain, soreness, stiffness, and, in severe cases, weakness, loss of mobility, and swollen, tender muscles. Severe ER is far more problematic than the milder form of DOMS or hyperCKemia, where CK levels are slightly elevated following a bout of exercise overload. Unlike hyperCKemia or DOMS, severe ER is a major health concern for any athlete. A challenge to the early recognition of ER for the athlete and clinician is that signs and symptoms during the triggering bout of intense exercise can be few and subtle. Importantly, signs and symptoms of severe ER can begin in the first few hours after the triggering exercise bout and tend to peak over the subsequent two days.

Severe Exertional Rhabdomyolysis.

The clinical diagnosis of severe ER soon after an overly intense exercise bout is a physician’s judgement call that hinges in part on the following features that help separate severe ER from the overlapping, but milder DOMS:

1. Muscle pain more severe and sustained than expected
2. Swelling of muscles and adjacent soft tissues
3. Weak muscles, especially in hip or shoulder girdle
4. Limited active and passive range of motion
5. Brown (“Coca-Cola”) urine from myoglobin

Confirmation and Diagnosis of Exertional Rhabdomyolysis.

A diagnosis of ER is made when there are muscle pain symptoms and a laboratory evidence, via blood and urine testing, of myonecrosis with release into the systemic circulation of muscle cell contents, including myoglobin, creatine, creatine kinase, organic acids, potassium, aldolase, lactate dehydrogenase, and hydroxybutyrate dehydrogenase. When clinical evidence of rhabdomyolysis is observed, such as muscle pain and weakness, then creatine kinase levels more than 5 times the normal level are accepted as evidence of significant muscle breakdown and generally considered consistent with a diagnosis of ER.

Referral Protocol for Exertional Rhabdomyolysis.

It is a priority that all athletic trainers, strength and conditioning personnel, and coaches prevent ER from occurring. It is vital to recognize ER early and activate the necessary emergency action plan. Any sign or symptom of rhabdomyolysis demands the immediate referral to either the team Physician, Urgent Care, or Emergency Medical Services.

Causes of Exertional Rhabdomyolysis.

There can be a cascade of events that lead to ER, such as: physical injury of a muscle, accelerated muscle metabolism due to substances (e.g., supplements) or underlying metabolic myopathies, hemoglobinopathies, and/or hyperthermia. ER often occurs when excessive exertion is combined with confounding variables, such as sickle cell trait, dehydration, use of certain drugs (e.g., statins, anticholinergics, amphetamines, anabolic steroids, glycyrrhizinic acid).

Risk Factors for Exertional Rhabdomyolysis.

ER in an NCAA student-athlete (SA) is commonly linked to three conditions:

1. Novel overexertion
2. Exertional heatstroke
3. Exertional collapse with complications in athletes with sickle cell trait

Novel Overexertion.

Novel Overexertion is by far the most common cause of ER; with early diagnosis and proper therapy, this condition is benign. ER from novel overexertion can lead to mild AKI, and/or muscle compartment syndrome, which if not treated promptly can lead to long-term disability. Novel overexertion is often characterized as irrationally intense workouts, specifically with excessive eccentric exercises, designed and conducted by coaches and/or strength and conditioning personnel. Eccentric exercise is when a muscle contracts as an external force tries to lengthen it. Even though almost every athletic workout has an eccentric component, ER often occurs when exertion is pushed beyond the point at which fatigue would normally compel an individual to stop; such as what can occur during group exercise under demanding supervision or peer pressure.

Tips for Prevention and Early Recognition of ER from Novel Overexertion.

1. Moderation. Avoid too much, too soon, too fast. Educate everyone in the athletics department conducting exercise sessions - especially the coaches/strength and conditioning personnel - on all aspects of ER from novel overexertion and the additive effect of all physical exertion on the athlete.
2. All training programs should start slowly, build gradually, include adequate rest, and allow for individual differences. Avoid reckless intensity in an effort to make everyone bigger, stronger and faster.
3. Workouts are meant to improve fitness, skills and athletic performance. They should be rational, physiologic and sport-specific. Avoid the use of additive physical activity as punishment or for building toughness.
4. Athlete’s physical readiness changes day to day. Encourage athletes to set their own pace or at least communicate with them frequently to learn if undue symptoms are developing. As the workout ends, watch them closely and ask them how they feel.  Athletes who are showing signs of physical distress should be allowed to set their own pace while conditioning.
5. Set the right tone. Workouts are to enhance performance, not to punish or intimidate. Never use exercise as a form of punishment in an athlete experiencing physical distress. Athletes should feel free to report any symptom at any time and obtain immediate help. Athletic trainers are authorized to step in to provide care for an athlete in distress at any time without retribution.
6. Fluids should be regularly available, and frequent breaks should be scheduled.
7. Post a urine-color chart in the locker room, and near urinals and restroom stalls. Athletes should report dark urine immediately.
8. Encourage athletes to read their body, cut back or stop if they start to struggle, and report immediately any concerning symptom, especially any peculiar, atypical or undue muscle discomfort, extremely  strenuous exercise  bout for  which  he was  not accustomed.

Treatment of Exertional Rhabdomyolysis.

The initial treatment of ER will be administered by the treating physician. General treatment includes rest, aggressive hydration (usually with intravenous fluids), and monitoring for metabolic consequences (such as renal failure and electrolyte abnormalities) as well as the development of compartment syndrome. For those who respond appropriately to hydration and rest without other complications from ER, activities can usually be resumed at a low level following a period of time after resolution of symptoms.

Determining Recurrence Risk Following Exertional Rhabdomyolysis. 

Following successful clinical recovery from ER, the SA will be risk stratified for potential recurrence and given necessary restrictions per the treating physician’s orders. The student-athlete’s risk classification may determine the eventual return to activity protocol.

Risk-Stratification.

There is no clear evidence-based consensus on assessing individuals at risk for recurrent ER events. This institution will follow the guidelines proposed by the Uniformed Services University of the Health Sciences Consortium for Health and Military Performance (CHAMP). CHAMP detailed high- and low-risk individuals based on presenting symptoms and initial 2 week recovery period. Both the high- and low-risk markers are a guide, and do not supersede clinical judgement.

High-Risk Guidelines.

To define the individual as “high-risk” for recurrence at least one of the following conditions must exist:

1. Delayed clinical recovery (more than a week of activity restriction)
2. Persistent CK elevation above 1,000 U/L, despite rest for at least 2 weeks
3. ER complicated by AKI that does not return to baseline within 2 weeks as evidenced by elevations in BUN/Creatine
4. ER after low to moderate workload
5. Personal or family history of ER
6. Personal or family history of recurrent muscle cramps or severe muscle pain that interferes with activities of daily living or athletic performance
7. Personal or family history (if personal status unknown) of sickle cell disease or trait
8. ER complicated by drug (e.g. statins, antipsychotics such as haloperidol, stimulant medications including amphetamines [Adderall] and methylphenidate [Ritalin and Concertal]) or dietary supplement use e.g. stimulants [e.g. caffeine, synephrine, octopamine, yohimbine, ephedra; for a list of other stimulants in supplements see: http://hprc-online.org/dietary-supplements/files/stimulants-found-in-dietary-supplements-pdf stimulants] and steroids) and energy drinks. Although supplements do not imply a medical condition that would necessarily warrant a MED or detailed work-up, individual as well as team education may be warranted
9. Personal history of significant heat injury
10. CK peak > 100,000 U/L

Low-Risk Guidelines.

In order to define the individual as “low-risk” for recurrence none of the high-risk conditions should exist, and at least one of the following conditions must exist:

1. Full clinical recovery within 1 week and laboratory values all normalized within 2 weeks with exercise restriction
2. Highly physically trained SA with a history of very intense training
3. Known participation in extreme conditioning program prior to ER event
4. No personal and family history of ER or previous reporting of exercise-induced severe muscle pain, muscle cramps, or heat injury
5. Existence of other ER cases in the same athletic team
6. Identifiable period of sleep and/or nutrition deficit
7. Concomitant viral illness or other infectious disease

Abnormal Recovery at Two Weeks after Injury.

If at 2 weeks after injury, clinical indicators are abnormal, the SA will be referred to or discussed with an appropriate specialist (e.g. neurologist, nephrologist, sports medicine physician) or regional consultant for further management and potential evaluation for an underlying disorder that may predispose to recurrent injury. The evaluation may include, but not limited to: EMG, muscle biopsy, caffeine-halothane contracture test, genomic/proteomic testing, and/or exercise challenges. Return to play and profiling are individualized based on results of testing.

Return to Play (RTP) Following Exertional Rhabdomyolysis.

Due to the lack of evidence-based RTP research, this institution will follow a guideline adapted from multiple peer-reviewed research. A typical RTP protocol can take up to 4 to 6 weeks, but progression through the stages will be determined by the team and/or treating physician on a case-by-case basis.

Phase I.

Once the SA is discharged from the hospital, the SA will return to activities of daily living. During this phase, the athletic trainers will assess the athlete daily (whether in-person or electronically) for recurring muscle soreness, hydration status, urine characteristics and ensuring SA obtained at least 8 hours of sleep. Prior to the beginning of Phase II the SA will be evaluated by the team and/or treating physician, at which time CK and serum creatine levels will be measured. The SA will progress to Phase II when the CK level is less than 5 times normal (1000 U/L). In addition clinical symptoms must remain absent and laboratory data remain within normal limits.

Phase II.

Following successful completion of Phase I, the SA will begin physical activity and functional movements/exercises. Based on a 6-day training week, the SA will engage in activity for no more than 3 consecutive days. Initially, activities will focus on stretching and non-weight bearing conditioning. If the SA does not develop muscle soreness, the later part of Phase II will introduce ground-based dynamic warm-ups, and body-weight functional movement exercises (e.g. Swiss ball, TRX), while avoiding primarily eccentric exercises. The resistance and time will gradually increase throughout this Phase. Prior to beginning Phase III the SA will be evaluated by the team and/or treating physician, at which time CK and serum creatine levels will be measured. The SA will progress to Phase III if the CK level remains less than 5 times normal (1000 U/L).

Phase III.

Phase III will introduce resistance training at a low percentage of the estimated 1-repetition maximum weight, prescribed and overseen by the strength and conditioning coach. Phase III will also include agility training, timed runs/sprints, and sport-specific exercises/drills. Prior to sport integration the SA will be evaluated by the team and/or treating physician, at which time CK and serum creatine levels will be measured. The SA will progress to sport integration if the CK level remains less than 5 times normal (1000 U/L). No further laboratory testing needed.

Sport Integration and Return to Play.

Upon completion of Phase III, the SA will continue to increase strength and conditioning with lifting, agility work, speed development, and resistance training under the supervision of the athletic trainers and the strength and conditioning coaches. Integration into full athletic activity will vary dependent on sport and the individual. Minute and repetition restrictions will be utilized to ensure successful full integration into all sporting activities. Prior to full clearance SA will have a final evaluation with team and/or treating physician.

Management Strategies for Mental Health

“The job is not to evaluate, council, or treat. Rather, it is to assist the individual in getting to the right treatment professional” - NCAA handbook

CMS Athletics is committed to providing resources to help our student-athletes address mental health issues, with the goal of creating a culture where mental health care is as normative as physical injury care. With that in mind, working in conjunction with Student Health Services (SHS) and Monsour Counseling and Psychological Services (MCAPS), as well as the Dean of Students Offices of each institution, we aim to provide guidance, access to licensed medical and psychological professionals, and any resources for referral as needed for our student-athletes. All of our athletic staff including athletic trainers, administrators, coaches, and support staff will follow the guidelines stated below.

Mental Health Emergency Action Plan (MHEAP)

A student-athlete’s mental health is every bit as important as their physical health and will be treated as such. Medical problems often have psychological or emotional consequences. Psychological problems (e.g. eating disorders, substance-related problems) have medical consequences. Given the inter-relationship between the physical and mental, it is helpful to think of student-athletes with mental health problems as “injured” - just as you would of a student-athlete who has a physical or medical problem. As with physical injuries, mental health problems may, by their severity, affect athletic performance and limit or even preclude training and competition until successfully managed and treated. By virtue of their positions, athletics staff may observe or otherwise become aware of signs or symptoms that a student-athlete is struggling with their mental health. Some examples are listed below:

Signs and Symptoms of Depression

• Low or sad moods
• Irritability or anger
• Feeling worthless, helpless and hopeless
• Eating and sleeping disturbances (increase or decrease)
• Decrease in energy and activity level with feelings of fatigue or tiredness
• Decrease in concentration, interest and motivation
• Social withdrawl or avoidance
• Negative thinking
• Thoughts of suicide or death

Signs and Symptoms of an Anxiety Disorder

• Excessive worry, fear or dread
• Sleep disturbances, especially difficulty falling asleep
• Changes in appetite, including either an increased need to eat when anxious or difficulty eating due to anxiety
• Feelings ranging from a general uneasiness to complete immobilization
• Pounding hear, sweating, shaking or trembling
• Impaired concentration
• A feeling of being out of control
• Fear that ne is dying or going crazy
• A disruption of everyday life

How to respond when the student-athlete approaches you

When an individual indicates a need to talk with you, the best way to respond is to listen. Listening is the most important part of communicating. Generally, wait to speak until the student-athlete stops talking or appears to be waiting for you to respond. It is alright to ask questions for clarification, but be careful not to judge or be critical.

How to respond when the student-athlete is in need and has not approached you

There are ways to reach out when you are concerned that a student-athlete is in need. If not you, then the person approaching the student-athlete should be a person of some authority. More important, however, is that this initial step be taken by someone who has a good relationship with the student-athlete or who is comfortable discussing important and sensitive issues. Even if you cannot understand the seriousness or difficulty of the student-athlete’s problem, you must accept that it is a serious problem for the individual. Depressive disorders, anxiety disorders, eating disorders and substance-related disorders are mental health problems in need of treatment. They are illnesses- not choices; that is why they are called disorders.

It is best to approach the individual privately to decrease the likelihood of embarrassment and to avoid any other activity that might distract you or the student-athlete. Sensitivity is a key in facilitating the discussion. Begin by saying you are concerned about the individual’s welfare and would like to help. Hopefully, this approach will allow the student-athlete the opening to talk with you about their difficulties.

Knowing Your Limits

Your primary responsibility is to recognize concerning behavior and refer. To avoid the student-athlete’s difficulties weighing too heavily on you, you need to know your limits. Be aware of what is reasonable to expect from yourself. When you begin to feel undue stress or worry, it is time to take care of yourself and turn the problem over to someone else. If a student-athlete demonstrates violence or a threat to self or others, an immediate escalation of the concern to the Dean of Students Office or MCAPS is required.

Procedures

Acute Emergent Mental Health Emergency

A mental health emergency may be a life-threatening situation where the behavioral status of an individual is highly concerning.

In the event of an acute emergent mental health emergency:

OFF CAMPUS: Call 911 and then follow on-campus procedure

ON CAMPUS:

• Immediately call Campus Safety:  x72000 or (909) 607-2000
  • Notification of Campus Safety will trigger an automatic notification to the Dean on Call
  • Do not leave the student-athlete alone
• If the student-athlete or you need to speak to a Counselor call:
  • Monsour Counseling and Psychological Services: (909) 621-8282 (after hours press 1)
• When calling, provide the following information:
  • Student-athlete’s NAME and CONTACT INFORMATION
  • Exact LOCATION of the student-athlete
  • DESCRIPTION  of the situation and ASSISTANCE NEEDED
  • If the student-athlete leaves the area or refuses assistance, NOTE THE DIRECTION in which they leave
• NOTIFY the DEAN OF STUDENTS directly:
  • CMC: (909) 621-8114
  • Scripps: (909) 621-8277
  • HMC: (909) 621-8125
• If you cannot contact Dean of Students, notify the DEAN ON CALL via CAMPUS SAFETY
  • (909) 607-2000 request Dean on Call for institution
• NOTIFY SPORTS MEDICINE
  • Sports Medicine Urgent Care Line: (909) 607-0043
  • Sports Medicine will follow up with:
    • Diretor of Athletics
    • Dean of Students
    • Team Physician
• DO NOT contact parent(s)/guardian(s)
  • Initial parental notification will be conducted by the Dean of Students office

An Acute Non-Emergent Mental Health Condition

A situation where a student-athlete is experiencing a mental health challenge such as: depression, persistent sadness, anxiety, homesickness, inability to cope with situational stressors, etc.

IN THE EVENT OF AN ACUTE NON-EMERGENT- MENTAL HEALTH CONDITION-ON or OFF CAMPUS

• Gather information and ask questions, including about their safety
• If student-athlete or you need to speak with a Counselor, call:
  • Monsour Counseling and Psychological Services: (909) 621-8202 (press 1 after hours)
• If during business hours, contact Dean of Students Office directly:
  • CMC: (909) 621-8114
  • Scripps: (909) 621-8277
  • HMC: (909) 621-8125
• If after busniness hours or unable to reach the Dean of Students, contact campus safety to talk to the on-call Dean: (909) 607-2000
• Notify Sports Medicine:
  • Sports MedicineUrgent Care Line: (909) 607-0043
  • Sports Medicine will follow up with:
    • Director of Athletics
    • Dean of Students
    • Team Physician
• DO NOT contact parent(s)/guardian(s)
  • Initial parental notification should be contacted through the Dean of Students office

Chronic Mental Health Condition

If student-athlete has a mental health diagnosis and is in need of treatment, the appropriate  Dean of Students will be alerted and they will collaborate with the student to coordinate mental health treatment on an individual basis.

If student-athlete is currently under the care of a mental health professional upon arrival to campus, it is encouraged that they contact the Dean of Students and the Sports Medicine staff so additional support can be provided if needed.

If coaches are aware of a mental health concern, they are to contact the Dean of Students and follow up with Sports Medicine staff.

Concern for Whereabouts of a Varsity Student-Athlete

A situation where a student-athlete has not been seen by coach(s) or teammates and there is no explanation as to why or explanation as to why is of concern. 

DO NOT CONTACT THE PARENTS OR GUARDIANS. The following steps should be taken:

•  Notify Dean of Students directly:
  • CMC: (909) 621-8114
  • Scripps: (909) 621-8277
  • HMC: (909) 621-8125
• If you cannont contact Dean of Students directly,notify Dean on Call via campus safety:
  • (909) 607-2000 ask for the On-Call Dean
• Notify Sports Medicine
  • Sports Medicine Urgent Care Line: (909) 607-0043

Crisis Lines

If a student-athlete is unable to participate in their sport as a result of a mental health condition, the student-athlete’s mental health provider in conjunction with the Dean of Students and the Team Physician, will determine a safe “return to sports participation” protocol on an individual basis.

If a student-athlete shows up to a practice/game w/o notification/clearance to return to sport from the Dean of Student’s Office, you should contact the respective Dean of Students Office to inquire.  If you cannot get in touch with Dean of Students Office, contact Sports Medicine for assistance.

Physician Agreement

I, _______________________________ agree to bear the responsibility of overseeing  the total health care of the student-athletes who participate in the Claremont McKenna-Harvey Mudd-Scripps Colleges Intercollegiate athletics program. The CMS certified athletic trainers will be under my guided supervision, but will be given flexibility to function within their scope of practice, within the defined written protocols, as outlined in this policies and procedures manual. The certified athletic trainer’s scope of practice is defined by (1) Board of Certification (BOC) Standards of Practice, (2) BOC Role Delineation (3) The National Athletic Trainers’ Association (NATA) Code of Ethics and the NATA Position Statements. I possess the authority in determining the health status of athletes who participate in the CMS Colleges Athletics program and will work with the CMSSMP to ensure that the appropriate quality of care is provided. Finally, I approve these written protocols, and will work directly with the CMSSMP to ensure proper implementation.

__________________________________ Physician Signature   

__________________________________ Assistant AD for Sports Medicine, Performance and Health

__________________________________ Athletic Trainer

__________________________________ Athletic Trainer

__________________________________ Athletic Trainer

__________________________________ Athletic Trainer

__________________________________ Athletic Director

__________________________________ Legal Counsel