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Medical emergencies are an inherent risk in any sport, transcending boundaries and impacting athletes globally. From a cervical spine injury on the (American) football field to a sudden cardiac arrest (SCA) on the soccer pitch or an exertional heat stroke during a high school track meet, the potential for emergencies underscores the importance of preparedness and vigilance at every level and in all sport settings. Despite their varying contexts and levels of medical resources, sports share a common vulnerability to emergencies, emphasising the critical need for proactive measures to safeguard the health and well-being of athletes. Indeed, preparedness is paramount for handling medical emergencies effectively.
To enhance athlete safety at sporting events, we propose the implementation of a pre-event medical meeting, referred to as the ‘medical time out’ (MTO). The objective of the MTO is to gather sports medicine and emergency care personnel prior to a game or competition to review the emergency action plan (EAP) and enhance coordination before an emergency occurs. The aim of this commentary is to highlight key elements of MTO and promote its adoption throughout sport.
Key considerations for an MTO
Given the unpredictable nature of medical emergencies during sport, facilitating a rapid and efficient response is essential to deliver optimal care.1–3 The MTO should be conducted prior to each sporting event and functions as a comprehensive checklist review of the venue’s EAP. Home and visiting team medical staff (athletic trainers, physiotherapists and team physicians), venue medical staff and on-site emergency medical personnel should be present for the MTO.
The National Athletic Trainers’ Association endorsed the MTO in 2012,4 and it has gained increasing recognition and application over the past 12 years. The term ‘time out’ is familiar in both sports and medicine. In sports, it is used for strategic discussions or play calls, while in medicine, presurgical timeouts are conducted before procedures to confirm critical details. Similarly, the MTO aims to optimise emergency medical care delivered on the field-of-play by reviewing response procedures and defining roles before an emergency occurs.
The MTO plays a pivotal role in establishing a coordinated emergency response, which can positively impact outcomes. Typically, athletic trainers or physiotherapists are the first responders in sporting emergencies, but other healthcare professionals, from physicians to emergency medical technicians, may also be involved. Including all responders in pre-event meetings ensures everyone is informed, as effective communication is vital for delivering optimal care.
Drawing inspiration from Dr Atul Gawande’s ‘The Checklist Manifesto,’ the MTO employs a basic checklist to guide actions and improve outcomes. ‘The Checklist Manifesto’, illustrated how simple checklists can significantly improve outcomes across various professions. The WHO surgical checklist has saved numerous lives in over 20 countries.5 An example in sports is the FIFA poster for emergency action planning, which supports and promotes a consistent level of emergency care on the soccer pitch.6 Healthcare providers can enhance athlete care during emergencies by crafting and implementing an EAP that incorporates the MTO and uses a basic checklist (box 1) to guide the meeting. By addressing these critical elements in advance, athlete healthcare providers are better prepared to respond effectively to emergencies, protecting the safety and well-being of athletes and participants.
Key aspects of a medical time out
Timing: athlete healthcare providers (and other athlete support personnel, as appropriate) should meet prior to the start of each sporting event to review the emergency action plan.
Role and location assignment: clearly determine the roles and locations of every individual, from athletic trainers and physiotherapists to emergency medical technicians to physicians, who will be involved in an emergency response. Understanding where each person is stationed and clearly defining roles is vital for a coordinated response.
Communication protocol: establish the method of communication and identify the primary and secondary means of communication; this may include voice commands, radio communication and hand signals. Having both primary and backup methods ensures redundancy in communication, even in challenging situations.
Emergency equipment: confirm the presence and location of emergency equipment. Clarify what type of equipment is available and where it is located (ie, an automated external defibrillator, a spine board and spinal motion restriction equipment, a cold tub for rapid cooling, airway equipment and trauma kits). Ensure that all equipment is regularly checked to ensure proper working order and readiness for immediate use.
Ambulance presence: an ambulance should be present, if possible, at all events when a high-risk of serious medical injury exists. Discuss the location, planned entrance/exit routes and unobstructed pathways. Determine the level of care that the emergency medical services personnel are providing, for example, advanced life support or basic life support. Clarify whether the ambulance is dedicated to the event or on standby. Have a contingency plan for calling an ambulance if it is not already on-site.
Designated hospital: identify the designated hospital in case of emergency transport. Select the most appropriate facility based on the nature of the injury or illness to ensure swift and suitable medical care. Considerations include hospitals capable of managing head and neck trauma, orthopaedic trauma and advanced cardiopulmonary resuscitative care.
Potential plan-altering factors: assess any potential issues that could impact the execution of the emergency action plan and adjust plans accordingly. This may include factors such as ongoing construction, road closures, adverse weather conditions or traffic and crowd flow dynamics.
Preparation for worst-case scenarios
The MTO should prioritise prompt recognition and initial management of potential catastrophic athlete injuries. Athlete healthcare providers should discuss management techniques for potential emergencies, including SCA (eg, rapid recognition with prompt cardiopulmonary resuscitation and defibrillation), head and spine injury (eg, specific attention to preferences for spinal immobilisation techniques and equipment as well as potential associated airway compromise), exertional heat illness (eg, covering core temperature measurement and rapid cooling techniques prior to transport), haemorrhage control and awareness of participating athletes with relevant medical conditions. It is imperative for athlete healthcare providers to stay updated on current consensus statements, evidence-based protocols and best practices7–10 and to regularly practice and rehearse these essential skills.
Emergency medical services (EMS) training officers and event organisers should encourage the development of venue-specific protocols for sporting events prior to event coverage, with a focus on injuries that are unique to that sport as well as preparedness for mass casualties.
EMS should strategically position ambulance units, staff and equipment to enhance the emergency response, especially in remote locations with limited resources. If both a portable automated external defibrillator (AED) and a manual defibrillator supplied by EMS are available at the sporting event, clarification of which device would be used in the case of SCA should be discussed during the MTO. A team approach that encourages direct communication between sideline athlete healthcare providers and EMS personnel enhances precision in responding to serious athlete injuries or life-threatening situations during sporting events.
Implementing the MTO in resource-limited settings
Medical professionals and emergency care personnel may not be present at many high school and youth sporting events and other resource-limited settings. When a medical professional is not present, the MTO should be led and attended by a designated coach (or other identified staff member) from the home and away teams. Lay responders can still effectively activate an EAP, call for EMS, begin cardiopulmonary resuscitation and retrieve and use emergency equipment. During the MTO, rescuer roles should be reviewed, as should the location of emergency equipment (eg, the closest AED).
Working examples of the MTO
The MTO has become the standard at all major professional sports leagues and many collegiate sporting events in the USA. The supplemental material provides examples of how the MTO has been successfully implemented from the professional sports level (eg, National Football League, Major League Soccer and National Hockey League) to intercollegiate sports to secondary school and youth sports (see online supplemental material).
Supplemental material
In conclusion, the MTO prioritises prompt recognition and management of catastrophic injuries, covering various emergencies such as SCA, head and spine injuries, exertional heat illness and haemorrhage control. By implementing the MTO, athlete healthcare providers will be better prepared to respond effectively to medical emergencies on the field-of-play. The MTO has been successfully implemented across various sports levels, from professional to youth sports, enhancing preparedness and prioritising athlete safety.
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Supplementary materials
Supplementary Data
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Footnotes
X @mickiscollins
Deceased This editorial is dedicated to Greg Elkins (12 May 1962 – 17 March 2024)
Correction notice This article has been corrected since it published Online First. The affiliations for Christianne Eason and Douglas Casa have been updated.
Contributors All authors made substantial contributions to the conception or design of the manuscript, assisted in drafting the manuscript or revising it critically for important intellectual content, approved of the final version of the manuscript to be published and agreed to be accountable for all aspects of the work.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.
Author note This editorial is dedicated to Greg Elkins, MD (May 12, 1962 - March 17, 2024).
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.