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EQUIPMENT REMOVAL

OVERVIEW

There is a growing body of evidence-based literature examining the effectiveness of various s equipment removal techniques as well as the appropriate timing of equipment removal from an athlete requiring transport to an appropriate medical facility.  Currently, there is no evidence to suggest that any one removal technique is safer than another.  Nor is there sufficient evidence to suggest the most appropriate time to remove equipment from an injured athlete.  Expert opinion is varied on the subject of equipment removal technique and timing as well.  The reason for such inconclusive evidence and varied expert opinion is likely due to the unpredictable nature of managing injury in the pre-hospital care environment.  Unpredictable factors such as weather conditions, protective equipment variations, and patient sequelae weigh heavily on pre-hospital management.  The mediating factor in all this variation, however, is that the medical team must always provide for the safest handling of the athlete.  This means that the medical team must have the psychomotor skills required to carry out all the various equipment removal techniques while having a firm cognitive understanding of when each techniques is most appropriate.  The appropriateness and timing of equipment removal cannot be dictated by an equipment removal protocol that relies on a single technique for all conditions..  Rather, a best-practice equipment removal protocol will rely on the decision of the medical team to employ the technique that provides for the safest handling of an injured athlete given the current condition.

There are three common conditions during which the medical team will be required to remove protective athletic equipment from an athlete.  The first condition is during a non-life-threatening injury scenario involving an athlete with stable vital signs and no neurological sequalae for whom the medical team has elected to transport to an appropriate medical facility for further evaluation.  The second condition is during management of a non-life-threatening injury scenario involving an athlete who presents with neurological sequalae, but who is otherwise stable.  The third condition is during a life-threatening emergency during which advanced cardiac life support and/or other critical care tasks may be required.

Non-Life-Threatening Equipment Removal

During a non-life-threatening injury scenario there are three leading philosophical approaches to equipment removal.  A point, counterpoint review of each approach is provided below.  These points shall be considered regularly as part of the annual review of safe handling practices.

Trauma Naked Approach

This approach involves removing all equipment on the field prior to transfer and transport.

Counterpoint: In a stable non-life-threatening situation properly fitted equipment facilities safe handling by aiding in maintaining immobilization during repositioning and transfer techniques.  In the event that the athlete’s condition changes, equipment can be removed quickly enough to provide any necessary critical care tasks.

Counterpoint: Most prehospital care providers have no specific training in athletic equipment removal techniques.  Athletic trainers are not experts simply because of their credential.  Becoming proficient and remaining proficient in equipment removal techniques requires regular practice that most do not undertake.  The result is equipment removal that is not any more efficient than the different safe handling techniques used by emergency room personnel.  In addition, the grass or turf makes pulling the shoulder pads out from under the athlete more challenging during the flat-torso technique, relative to the flat surface of a spine board.  Finally, removing equipment while on the field is harder because the medical team is not in an ergonomically advantageous position, relative to the raised height of a gearnie or emergency room table.

Primary Objectives Approach

This approach involves dealing only with equipment that hinders care required to rapidly stabilize the athlete while on the playing surface with the goal of quickly transporting them from a very chaotic environment to a more controllable environment.  Proponents of this approach feel that safe handling is ultimately more effective when the athlete is in an environment that can be ultimately controlled.  The field of play has many distractions, including media, other players, coaches, parents, bystanders, and additional stresses associated with being in the public eye.  Typically, proponents of this philosophy will remove the face mask while leaving the jersey and shoulder pads intact prior to transport from the field.  Depending on the signs and symptoms present, medical teams may elect to remove the face mask to gain access to the airway, and cut the jersey and shoulder pads to provide access to the thorax, but leave the helmet and shoulder pads on the athlete during evacuation from the playing surface.  Some teams may elect to transport with the equipment in place or with it prepped, but still on the athlete, while others will ultimately remove all the protective athletic equipment prior to transport to an appropriate medical facility.  In any case proponents of this approach generally perform equipment removal procedures once the athlete has been removed from the field, is in the back of the ambulance, or is in the ED.

Counterpoint: some transfer techniques, such as the scoop stretcher protocol, have been shown to be complicated by protective athletic equipment, field conditions, and with larger athletes.

ED Philosophy

Proponents of this philosophy generally believe that the emergency room is ultimately the most controlled environment, and ultimately the best place to remove equipment from the athlete.  Proponents of this philosophy will generally transport the athlete one of two ways.

  1. With the facemask removed;
  2. With the face mask removed and the chest exposed by prepping the jersey, shoulder pads, and undergarments.

Counterpoint: Proponents of this approach generally have large medical staffs, including athletic trainers, paramedics, physicians, trauma surgeons, etc.  They often have many more resources available to them that allow the medical team to provide a consistent high level of care throughout the entire continuum of care.  Proponents of this philosophy often will provide an experienced athletic trainer as an escort during transport, all EMS providers will are specifically trained, and a police escort may be provided to expedite transport to an appropriate medical facility.

Life-Threatening Injury Equipment Removal

During a life-threatening injury scenario there are two leading philosophical approaches to equipment removal.  A point, counterpoint review of each approach is provided below.  These points shall be considered regularly as part of the annual review of safe handling practices.

Trauma Naked Approach

Proponents of this philosophy will suggest that if there is a life-threatening condition, they prefer to begin management by removing all of the equipment.  These individuals believe that overall critical care task completion is facilitated with the prior removal of all equipment.  The belief is that the overall improved ability to more effectively administer advanced care throughout the entire continuum of care far outweighs the minimal delay in onset of critical care from first removing the equipment.

Counterpoint: Anecdotally, medical teams that are well practiced and have a choreographed plan for equipment removal can remove equipment from an athlete very quickly.  However, there is some literature to suggest that medical teams can initiate chest compressions and AED application sooner by leaving the helmet and shoulder pads in place, but cutting the jersey, shoulder pad strings, and straps, and cutting any undergarments to expose the chest.  Likewise, research indicates that the airway of an injured athlete can be accessed sooner by removing only the facemask to initiate airway management, relative to complete helmet removal or helmet and shoulder pad removal.

Primary Objective Philosophy

Proponents of the primary objectives philosophy will suggest that the expeditious care of cardiac, airway, and breathing complications is facilitated by only dealing with a particular piece of equipment that is a liability to the medical team’s immediate critical care objectives.  Proponents of this philosophy feel that it is better to leave the equipment in place unless it becomes a liability to the team’s immediate care objectives.  With this approach, complete equipment removal is reserved for after the athlete has been stabilized and is being transferred and prepared for transport.

Counterpoint:  As stated above, others believe that if the equipment is going to have to come off, it should be done so sooner than later to facilitate immediate care and care provided throughout the entire continuum.

Techniques

Face Mask Removal

FMxtractor® Face Mask Removal Video Demonstrations Library    
  Series begins with intro to the FMxtrator® functionality and proceeds through face mask removal techniques for all the various helmets and attachment systems presently in use.
     

In accordance with current practice standards, the  medical staff employs the Combo-Tool Approach to face mask removal when face mask removal is required to provide emergent or non-emergent access to an injured patient’s airway.

Small, low voltage hand held power screwdrivers (PSD) are used to reduce the risk of stripping face mask hardware screws.  The directional buttons of all PSDs are locked and taped in the reverse direction to avoid accidentally tightening helmet hardware to reduce the risk of accidentally tightening or stripping hardware.  A phillips style screw driver bit is glued into the end-effector of all PSDs to avoid having them fall out and lost while being stored in emergency kits.  PSDs are taken out of all emergency kits following each and every event, and are plugged in to ensure they are fully charged.  Each PSD is tested for proper function prior to being packed for event use.  FMx3 functionality is checked prior to each event and the blade lubricated with a silicone based lubricant before each event.

If face mask removal is delayed or complicated to the point of disrupting completion of other primary objective critical care tasks, the A-Man or designated code runner will direct the team to initiate the helmet removal protocol.  Generally, the criteria to abort the face mask removal procedures and initiate the helmet removal protocol is met if face mask removal cannot be completed prior to the start of the second cycle of CPR, or approximately 2 min.  The A-Man or designated code runner will ultimately determine the appropriateness of helmet vs. face mask removal on a case by case basis.

A-Man

B- and C-Man

Helmet Removal

Removal Technique Review Videos for Various Modern Helmets

Riddell SpeedFlex    
   
 

Conditions which may warrant removal of the football helmet from an athlete may include, but are not limited to:

  1. Inability to gain access to the injured athlete’s airway with face mask removal;
  2. Inability to perform sufficient injury assessment;
  3. Desire to have access to stable or unstable athlete during transport.

When it is determined that the football helmet should be removed from an athlete, the following removal procedure shall be followed:

  1. The A-Man shall maintain in-line stabilization of the head and neck;
  2. The B- and/or C-Man shall prepare the helmet for removal by cutting the chin-strap and removing the mouth guard. In some helmet models removal of cheek pads, and deflation of air bladders may facilitate helmet removal.  In the event that the B- and C-Man are occupied with completion of other critical care tasks, extended members of the Critical Care Triangle™(CCT) shall be directed to prepare the helmet for removal.
  3. The B- or C-Man shall take control of and maintain in-line stabilization of the athlete’s head and neck by reaching in from the side to wrap hands around the neck such that the thumbs run along the mandible, coming to rest at the temporal-mandibular joint, while the fingers interlock to support the cervical spine posteriorly. Extended members of the CCT may be assigned this task in the event that B- and C-Man are completing other necessary critical care tasks.
  4. Upon securing in-line stabilization B- or C-Man shall iterate to the A-Man that they have sufficient control of in-line stabilization, upon which the B- or C-Man shall count “1-2-3, Release” to officially take control of the in-line stabilization from the A-Man.
  5. The A-Man will begin the helmet removal process by first removing all pack-n-fill towels used to maintain cervical neutral position;
  6. The A-Man will the begin helmet removal by slightly spreading the helmet at the earholes, then will carefully begin pulling the helmet from the athlete until the athlete’s ears are just about to clear the helmet cheek pads, at which point the A-Man shall pause helmet removal;
  7. The A-Man shall next iterate to the team member providing stabilization that the athlete’s ear are about to clear the helmet cheek pads and that helmet removal will resume on the count of “1-2-3, Remove”. This allows the team member providing in-line stabilization ample time to prepare to mediate a rebound force often observed to cause significant movement of the cervical spine when the helmet cheek pads slide over the athlete’s ears during football helmet removal.  Upon the “1-2-3, Remove” command, the A-Man shall resume extraction of the helmet by pulling the helmet while tipping the helmet slightly forward to clear the occiput posteriorly, but being careful to not hit the athlete’s nose when the face mask is still in place.
  8. Once the football helmet has been removed the A-Man shall pack-n-fill the athlete in cervical neutral position and then retake control of in-line stabilization by placing arms along the lateral aspect of the athlete’s head and placing the web space of hands on the athlete’s traps bilaterally with the thumbs on the collar bone, thus securing the head and neck to the torso.
  9. The A-Man shall iterate to the team member presently maintaining in-line stabilization that they properly positioned and are ready to re-take control of in-line stabilization, at which time the A-Man shall count “1-2-3, Release”. The A-Man shall now have control of in-line stabilization.
  10. The CCT will then resume prudent on-going assessment, care, and support of the athlete’s vital signs.

Removal Technique Review Videos for Various Modern Helmets

Helmet and Shoulder Pad Removal

The need to assess status of respiration;Conditions which may warrant removal of both the football helmet and shoulder pads from an athlete may include, but are not limited to:

  1. The need to assess effectiveness of ventilation;
  2. The need to perform CPR;
  3. Proper placement of defibrillator pads;
  4. Inability to perform necessary injury assessment;
  5. The need to perform critical care tasks associated with internal injury
  6. Desire to have access to stable or unstable athlete during transport.

When it is determined that the football helmet and shoulder pads should be removed should be removed from an athlete, the following removal procedures shall be considered:

Flat-Torso Technique

  1. The A-Man shall maintain in-line stabilization of the head and neck;
  2. The B- and/or C-Man shall prepare the helmet for removal by cutting the chin-strap and removing the mouth guard. In some helmet models removal of cheek pads, and deflation of air bladders may facilitate helmet removal.  In the event that the B- and C-Man are occupied with completion of other critical care tasks, extended members of the Critical Care Triangle™(CCT) shall be directed to prepare the helmet and shoulder pads for removal.
  3. The B- and/or C-Man shall prepare the shoulder pads for removal by first cutting the athlete’s jersey with heavy-duty bandage shears, beginning at the neckline and cutting down away from the athlete at the midline, and cutting laterally across each shoulder all the way through the arm sleeve cuffs.
  4. Next, in order to reduce the potential onset of a rebound force caused by the release of elastic tension in the shoulder pads straps upon cutting the breast plate strings, the B- and/or C-Man shall cut the shoulder pad elastic straps BEFORE cutting the laces and/or breast plates. In some instances, shoulder pads secured anteriorly with thick plastic plates may be removed without first cutting the plastic breast plate.  This option is more likely in smaller athletes and less likely with larger athletes.  The medical team will be able to assess this option upon observation of shoulder pad fit once the jersey, straps, and strings have been cut.
  5. Next, the B- or C-Man shall cut the athlete’s undergarments with heavy-duty bandage shears by beginning at the neckline and cutting down away from the athlete at the midline, and cutting laterally across each shoulder all the way through the arm sleeve cuffs to expose the chest.
  6. The B- or C-Man shall take control of and maintain in-line stabilization of the athlete’s head and neck by reaching in from the side to wrap hands around the neck such that the thumbs run along the mandible, coming to rest at the temporal-mandibular joint, while the fingers interlock to support the cervical spine posteriorly. Extended members of the CCT may be assigned this task in the event that B- and C-Man are completing other necessary critical care tasks.
  7. Upon securing in-line stabilization B- or C-Man shall iterate to the A-Man that they have sufficient control of in-line stabilization, upon which the B- or C-Man shall count “1-2-3, Release” to officially take control of the in-line stabilization from the A-Man.
  8. The A-Man will begin the helmet removal process by first removing all pack-n-fill towels used to maintain cervical neutral position;
  9. The A-Man will the begin helmet removal by slightly spreading the helmet at the ear holes, then will carefully begin pulling the helmet from the athlete until the athlete’s ears are just about to clear the helmet cheek pads, at which point the A-Man shall pause helmet removal;
  10. The A-Man shall next iterate to the team member providing stabilization that the athlete’s ear are about to clear the helmet cheek pads and that helmet removal will resume on the count of “1-2-3, Remove”. This allows the team member providing in-line stabilization ample time to prepare to mediate a rebound force often observed to cause significant movement of the cervical spine when the helmet cheek pads slide over the athlete’s ears during football helmet removal.  Upon the “1-2-3, Remove” command, the A-Man shall resume extraction of the helmet by pulling the helmet while tipping the helmet slightly forward to clear the occiput posteriorly, but being careful to not hit the athlete’s nose when the face mask is still in place.
  11. Once the football helmet has been removed the A-Man shall grasp the shoulder pads and gently pull them from under the athlete. The medical team may elect to perform a torso-lift or flat-lift technique to ease shoulder pad removal.  The medical team may elect to have extended members of the CCT aid in shoulder pad removal by grasping the shoulder pads on either side of the athlete.
  12. Once the football helmet and shoulder pads have been removed the A-Man shall pack-n-fill the athlete in cervical neutral position and then retake control of in-line stabilization by placing arms along the lateral aspect of the athlete’s head and placing the web space of hands on the athlete’s traps bilaterally with the thumbs on the collar bone, thus securing the head and neck to the torso.
  13. The A-Man shall iterate to the team member presently maintaining in-line stabilization that they properly positioned and are ready to re-take control of in-line stabilization, at which time the A-Man shall count “1-2-3, Release”. The A-Man shall now have control of in-line stabilization.
  14. The CCT will then resume prudent on-going assessment, care, and support of the athlete’s vital signs.

Torso-Lift Technique

  1. The A-Man shall maintain in-line stabilization of the head and neck;
  2. The B- and/or C-Man shall prepare the helmet for removal by cutting the chin-strap and removing the mouth guard. In some helmet models removal of cheek pads, and deflation of air bladders may facilitate helmet removal.  In the event that the B- and C-Man are occupied with completion of other critical care tasks, extended members of the Critical Care Triangle™(CCT) shall be directed to prepare the helmet and shoulder pads for removal.
  3. The B- and/or C-Man shall prepare the shoulder pads for removal by first cutting the athlete’s jersey with heavy-duty bandage shears, beginning at the neckline and cutting down away from the athlete at the midline, and cutting laterally across each shoulder all the way through the arm sleeve cuffs.
  4. Next, in order to reduce the potential onset of a rebound force caused by the release of elastic tension in the shoulder pads straps upon cutting the breast plate strings, the B- and/or C-Man shall cut the shoulder pad elastic straps BEFORE cutting the laces and/or breast plates. In some instances, shoulder pads secured anteriorly with thick plastic plates may be removed without first cutting the plastic breast plate.  This option is more likely in smaller athletes and less likely with larger athletes.  The medical team will be able to assess this option upon observation of shoulder pad fit once the jersey, straps, and strings have been cut.
  5. Next, the B- or C-Man shall cut the athlete’s undergarments with heavy-duty bandage shears by beginning at the neckline and cutting down away from the athlete at the midline, and cutting laterally across each shoulder all the way through the arm sleeve cuffs to expose the chest.
  6. The B- or C-Man shall take control of and maintain in-line stabilization of the athlete’s head and neck by reaching in from the side to wrap hands around the neck such that the thumbs run along the mandible, coming to rest at the temporal-mandibular joint, while the fingers interlock to support the cervical spine posteriorly. Extended members of the CCT may be assigned this task in the event that B- and C-Man are completing other necessary critical care tasks.
  7. Upon securing in-line stabilization B- or C-Man shall iterate to the A-Man that they have sufficient control of in-line stabilization, upon which the B- or C-Man shall count “1-2-3, Release” to officially take control of the in-line stabilization from the A-Man.
  8. The A-Man will begin the helmet removal process by first removing all pack-n-fill towels used to maintain cervical neutral position;
  9. The A-Man will the begin helmet removal by slightly spreading the helmet at the ear holes, then will carefully begin pulling the helmet from the athlete until the athlete’s ears are just about to clear the helmet cheek pads, at which point the A-Man shall pause helmet removal;
  10. The A-Man shall next iterate to the team member providing stabilization that the athlete’s ear are about to clear the helmet cheek pads and that helmet removal will resume on the count of “1-2-3, Remove”. This allows the team member providing in-line stabilization ample time to prepare to mediate a rebound force often observed to cause significant movement of the cervical spine when the helmet cheek pads slide over the athlete’s ears during football helmet removal.  Upon the “1-2-3, Remove” command, the A-Man shall resume extraction of the helmet by pulling the helmet while tipping the helmet slightly forward to clear the occiput posteriorly, but being careful to not hit the athlete’s nose when the face mask is still in place.
  11. Once the football helmet has been removed, an additional responder, or D-Man shall assume the position vacated by the team member who is presently responsible for stabilization.  The D-Man, together with the remaining B- or C-man shall position themselves at each shoulder of the athlete, and place their hands between the athlete’s shoulders and the shoulder pads.  Upon the A-Man command, the responders at the athlete’s shoulders gently lift the athlete to elevate the torso 30º to 40º by bending the athlete at the waist.  The pads are then removed by the A-Man.
  12. After the pads are removed, the A-Man directs the team to lower the athlete to the supine position where the A-Man re-assumes control of the head and neck.  Transfer of stabilization is again done by a “1-2-3 release” command given by the A-Man.  The A-Man then repositions the athlete to cervical neutral position.

Ancillary Content

Current Trends in Equipment Removal White Paper Sessions

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