Lesson 1:
The management of significant trauma or medical conditions is complex and beyond the scope of this module. It is essential that a team doctor, stadium doctor or other clinicians working in football have a clear process for the assessment of medical and trauma emergencies. Having the appropriate equipment on site is also essential. The FIFA Medical Emergency Bag contains the equipment needed to manage the more common medical and trauma emergencies which might occur on the field of play.
It is always important to make sure that you have help. As soon as you suspect that you are dealing with a more significant problem, your first action should be to call for help. This usually means calling an ambulance if there are no other healthcare providers on site.
A basic approach involving a “primary survey” is outlined below. This involves treating the greatest threat to life first. The lack of a definitive diagnosis should not delay the treatment of life (or limb) threatening conditions.
Safety:-
An important part of the administration of any medical support is the safety of all people involved. The first active role of the clinician is to ensure their own safety and then the safety of the persons who require treatment. If the field is not safe to enter, for whatever reason, do not enter the field until it has been declared safe by the referee or local security personnel.
The risks on any football field are going to be reasonably well controlled. It is always worth taking a few seconds to make sure the area is safe and, if necessary, stop the match or training session while first aid treatment is carried out.
- Safety issues specific to a football pitch include:
- Other players – there may be arguments going on among opposing team players
- Spectators – pitch invasion by spectators, throwing of missiles onto the field of play
- Unsuitable pitch conditions – uneven or slippery surfaces
- Adverse weather conditions – e.g. lightning
It is also important to protect yourself from potentially contaminated body fluids. Use gloves and consider the use of eye protection and other protective clothing. The FIFA Medical Emergency Bag (FMEB) contains gloves and a pair of goggles.
Airway:-
The first stage of the assessment is to assess the player’s airway – with cervical spine protection. Look inside the player’s mouth to assess if anything is blocking their airway. Examples of items that may block a player’s airway on the field of play include the following:
- A loose and poor fitting mouthguard
- blood or vomit in the mouth
- broken and loose teeth
- mud (especially if the ground is wet and the player falls face down)
The airway can be opened by tilting the head backwards if there is no potential of a neck injury being present. If there is suspicion of a neck injury or trauma involved, then lift up the chin or do a jaw thrust. Any obvious obstructions should be removed if they are clearly visible and to the front of the mouth, use the Magill forceps from the FMEB. Do not place your fingers inside their mouth. If it is not possible to protect the airway using these simple manoeuvres, it may be necessary to insert an “airway adjunct” from the FMEB. If the player is on their side, you should leave them there until help arrives. If the player is prone, gently turn their head to the side enough to enable breathing. If the player is unconscious, they should be placed on their side (not their back).
The FIFA Emergency Medical Bag contains laryngeal masks, nasopharyngeal tubes and Guedel airways. There are also a ventilation bag and masks.
Breathing:-
Use a stethoscope to assess the player’s breathing. Remember that players who have suffered a sudden cardiac arrest may be breathing normally.
The aim of this assessment is to identify and manage six life-threatening thoracic conditions. These are: airway obstruction, tension pneumothorax, massive haemothorax, open pneumothorax, flail chest segment with pulmonary contusion and cardiac tamponade. Most of these conditions are rare in football.
If the player is breathing normally, continue with the assessment. If they are not breathing, CPR should be initiated.
Circulation:-
Look for and stop any external bleeding. Haemorrhage is the predominant cause of preventable post-injury deaths. If there is bleeding, applying direct pressure is the first response. Deep and firm direct pressure is applied to control the bleeding. Cover the area with your gloved hand and a (sterile) towel (if you have one).
One must also consider the possibility of internal bleeding. Tachycardia or reduced blood pressure may be the only sign of this.
The FIFA Medical Emergency Bag contains equipment to manage bleeding, including a variety of gauzes and tape for the compression of wounds. There is also a blood pressure cuff and stethoscope. An infusion set, tourniquet and IV lines are included and can be used to deliver IV fluids to support the player’s circulation.
Disability:-
A basic neurological assessment should be made, known by the mnemonic AVPU (alert, verbal stimuli response, painful stimuli response, or unresponsive). This is achieved by noting whether:
- the player is fully alert and responsive to you
- the player is not alert but is responsive to your voice
- the player is not alert but does respond to your touch or to a painful stimulus e.g. earlobe squeeze
- the player is totally unresponsive – does not respond to any of the above
Hypoglycaemia and drugs, including alcohol, may influence the level of consciousness. The FIFA Medical Emergency Bag includes a glucometer which can be used to assess blood glucose.
Exposure and examination:-
You cannot treat what you cannot see. You must be able to see the injury in order to be able to effectively treat it. Injuries may be hidden under the player’s clothing.
Expose the relevant injury by removing as much clothing as necessary to look for underlying injuries. You must also consider whether removing the players clothing is going to create more issues. For example, this may predispose them to becoming cold and developing hypothermia. It is also important to consider the player’s privacy.
Consider the player’s medical history that you are aware of so that you can pass this information on to the ambulance staff on arrival.
Once these steps have been completed, resuscitation efforts are underway and the player is stabilised (vital signs are normalising), a further evaluation (secondary survey) should be conducted. This involves a head-to-toe evaluation of the player, including a complete history and physical examination and a reassessment of all vital signs. In a football context, this can be done in the medical room or changing room before transfer to hospital. Each region of the body must be fully examined. During this phase, X-rays may be obtained. If at any time during the secondary survey the patient deteriorates, another ABCDE assessment must be carried out as a potential life threat may be present.
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