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35th NACDA Convention
Orlando, Florida
June 11-14, 2000

NCAA Division III Breakout Session
Current Issues in Division III Medical Coverage in Athletics Training
Monday, June 12, 11:30 a.m.-12:15 p.m.

Art Eason

Good morning. I'm Art Eason, the director of athletics at William Patterson University and a member of NACDA's Executive Committee. It's my pleasure to serve as the moderator on this panel today, "Medical Coverage in Athletics Training."

To start, this March, the National Athletics Trainers Association issued its much anticipated recommendations and guidelines for appropriate medical coverage of intercollegiate athletics. In its preference, it reported two trends in college athletics are on a collision course. The first one deals with more, more teams, more nontraditional seasons, more strength and conditioning sessions. These result in more athletics injuries occurring.

The second trend is a legal one. It deals with sports-related athletics injuries. Instead of these sports-related athletics lawsuits being against equipment manufacturers for failing to warn us of a flaw in some piece of athletics equipment that has been manufactured, the new defendant in these lawsuits are now our universities.

There are concerns about how the universities properly trained health care professionals? Are there enough of them? Do the health care providers have adequate plans to follow? Are the proper records kept to maintain? Do our health care providers deliver proper treatment?

The NATA reports that universities have not kept up with the first trend and may not be providing appropriate medical care for our athletes. Institutions unaware of the second trend may not have proper plans either for appropriate medical care or for appropriate legal defense.

This is the crux of the problem. To guide us through the topic today, we have three highly knowledgeable panelists. The first if Jerry Shellard, the assistant athletics director for athletics medicine at Rhode Island College. He has a BS in physical education with emphasis in sports medicine from Keane State. He has a Master of Education in Athletics Training from Old Dominion. He's an adjunct professor at Rhode Island College teaching prevention and care of athletics injuries and also advanced prevention and care of athletics injuries.

Prior to coming to Rhode Island, Jerry was director of sports medicine at Quinnipiac College, where he also served as an adjunct professor. There, he taught introduction to athletics training, care and prevention of athletics injuries and a physical therapy class. Jerry will tell us about the program at Rhode Island College.

Jerry Shellard

Thank you very much. When I was first asked to discuss this topic with everyone, I had a curiosity factor when I was reading Denny's Task Force Report. I'm sure everyone is familiar with the Gettysburg situation where a lawsuit has been settled. That was 12 years ago. I took a survey of about 15 Division III institutions around the New York and New England areas to find out how they cover their nontraditional seasons. I looked at 15 schools and only three of the schools cover games that are going on. Only two of the schools cover practices, as well. Other than that, most of the institutions, at this point, still are not covering the fall baseball and softball practices and games. From the liability access that's already been discussed by Art, it's still not being addressed at a lot of institutions around the Division III area.

One of the other questions I asked within the survey is the number of varsity teams, the number of full-time athletics trainers on your staff. One athletics training staff is responsible for 29 varsity sports, five JV teams and 14 club teams for a total of 48 teams with only two certified athletics trainers.

From my survey, I also found that the number of trainers per varsity teams came to being one certified athletics trainer for every nine and one-half sports. One of the things we try to do at Rhode Island College is trying to get some control over that situation. When I first came on board, I was the only athletics trainer on the staff. In the time I've been there, we've added a second full-time position. We do not have a student trainer education program in place. With the new bylaws coming down for certification, we don't have a program in place for that.

One of the things we do to cover all of our sports and we do cover fall baseball and softball, is our athletics director gives me the ability to control the practice schedule. All of our coaches have to submit a practice schedule one month in advance. This schedule also includes their games as well as practice times. We end up with the final say about when teams practice. For instance, in basketball, we'll block off five or six hours or how much time that you want to have practice, but the men's team will practice 3:00 to 5:00, the women will practice 5:00 to 7:00. We also have wrestling, gymnastics and indoor track. In order to accommodate what they want to do for practice schedules, we have to have some control. Does it always work? Is it always a happy environment? No.

Last winter, our men's and women's basketball coaches both wanted to go at 3:00 p.m. and one wanted to use one facility and the other another facility. I have the authority to say, no, that's not going to happen and I have the backing of my athletics director. We work out a compromise in that situation and make everybody happy. Let the athletics training staff be part of the scheduling program for practices. That way, we know when practices are scheduled. There's nothing that is out of the blue and when the practices have been approved, there are not changes to it. If a coach has a bad game on a Friday or Saturday night and he wants a practice on Sunday morning and it's not on the schedule, he can't have it.

One of the other things we also do is we have two separate facilities. We have one facility that is strictly athletics. The other facility is for intramurals and recreation. One of the things we tend to do is that if a practice or a game is scheduled in the athletics center, the sports management staff will cover that. If the kids want to play a pick-up game of basketball in September, they go to the recreation center and use the intramurals. We don't have the responsibility. We separate them as being student-athletes in the athletics building and being students in a part of the student population in the recreation and intramural side of it. When they're up there playing intramurals, that is not our responsibility. Within the recreation and intramural staffing, they have a staff that is trained in first aid and CPR in emergency procedures. If somebody does sprain an ankle or twist a knee, those injuries are taken care of by that staff. It's not the responsibility of the sports medicine staff.

That relieves us of a lot of pressure. Denny will probably talk about the preseason basketball and conditioning, etc. At our Division III level, we have very specific start and end times. Our basketball season starts October 15, not September 1, like Division I. We know October 15 is basketball day, but before that our kids are on campus and they're playing intramural and pick-up, but that's not our deal yet. They are in their own environment. They're students at that point.

The other things we use and this was brought up in the Gettysburg case is that the coaches weren't certified in first aid and CPR. This is mandatory for employment at our institution. They must be first aid and CPR certified. If their certification runs out or they do not have it, they are suspended until that certification is renewed.

Also, in the Gettysburg situation, was the lack of radio or telephones to summons the EMTs and 911 services. All of our coaches are informed that they are not allowed to begin a practice until one of the trainers is on site or they have our radio system. We have two channels. One is for straight athletics and one is for a direct line to security. That is the way we initiate our EMS system. If we turn the channel over to security and tell them we need an ambulance at the baseball field, it's done that quickly. With the coaches being certified in first aid and CPR, we have some control and these are people who know what to do.

With me teaching the class, the first aid kit is given to them and we go through everything in that kit. We show them how to use everything, how to handle blood with OSHA regulations. We talk them through the entire kit.

One of the other things with the new legislation about to be proposed, being in Rhode Island and in a very small state, there is a rumor at the State House about the use of EMTs in the high schools. That law is already on the books. The EMTs are to be on site to cover varsity football games. There has been legislation and talk about expanding that legislation to cover college athletics as well. At this point, it doesn't present a priority to have an EMT on site. Nothing has been formally done yet, but that rumor is going around.

Another thing concerning Denny's formula is that we are required to have six full-time athletics trainers. Right now we have two. Do I think we need six? I don't think we need to have that number as high. Fall is our heaviest time of year. After that, winter and spring, we only have four teams going at once so to tell my president that we need an additional four certified athletics trainers full-time and only have four teams practice at one time, would not be acceptable. We probably only need about one half-time person. With our scheduling and the proximity of our facilities, that would be enough.

Peg Brown spoke earlier about how our old facility burned down and we developed a state-of-the-art new facility. We also have a training room right on the floor of the gym. During practice, we can have basketball practice going on and they can have their six baskets. There are bleachers that divide this and on the opposite side gymnastics can practice on a full set up. Our bleachers are movable and we can spin those around. We only need one athletics trainer to cover both varsity sports. Within all of that, we block off our practice time. We tell them they have a five- or six-hour block, and they are to pick their preferable time to practice. We feel we have pretty good control of when our practices are going on. With our radio and telephone abilities we have good access to the fields.

Art Eason

Thank you Jerry. We now have Denny Miller, who is the athletics trainer at Purdue University. He is also a physical therapist at Purdue. Denny received his bachelor's degree from Iowa State in physical education. His master's degree came from Syracuse. He has also received a postgraduate certificate in physical therapy from the University of Pennsylvania. He has been and is an instructor in the NATA, approved curriculum in the Department of Health. He is an assistant professor and he has been a curriculum director again, of a NATA approved program. He most recently chaired the Task Force for the Appropriate Medical Coverage in Intercollegiate Athletics.

Denny Miller

Thank you very much. It's a pleasure to be here. I think what I'm going to talk to you about may appear to be somewhat controversial, however, when you look at this and take this back to your campus and start to apply it to your situation, you're going to find that this is a very workable set of guidelines. I'd like to emphasize to you that they are only a set of guidelines.

In February 1998, the National Association of Athletics Trainers created the Task Force to establish appropriate medical coverage for intercollegiate athletes. This was brought about by the recommendation of our College Athletics Trainers Committee within NATA. It came about after essentially years of attempting to go through various committees through the NCAA and the NAIA to get our sponsoring organizations to look very carefully at appropriate medical care for our intercollegiate athletes.

The Task Force was represented by NCAA Divisions I, II and III, the NAIA and the divisions in the National Junior College Athletics Association. We had membership throughout our own association as well. In addition to that, we went to the American College of Sports Medicine, the American Orthopedic Society for Sports Medicine, the American Medical Society for Sports Medicine, the primary medical groups that provide the expertise from our team physicians. We issued an invitation to the NCAA, the NAIA and junior college folks to assist us along the way.

We asked each of these groups for the opportunity to provide the document to them so they could review it externally before we presented it to the National Athletics Trainers Association for its approval. We did do all of those things.

The mission of what we were charged with as a task force was to establish guidelines for appropriate medical coverage in order to provide the best possible health care for all student-athletes without discrimination. We wanted to address the student-athlete welfare issue with regard to the quality and standard of medical care that is afforded to them. I don't have to dwell on the increase in numbers of our participation, etc. I was given a cute line just before I came up here from Joe Godec from the University of Virginia. He said that when he started at Virginia, they had eight or nine recreational sports. Now, they have 18 or 19 occupational sports. I thought that summed it up quite well.

In addition, there's been expansion in the nontraditional season. It varies from division to division, from NAIA to junior college and to Division I. We understand that. Yes, at Rhode Island, you have a situation when, in August, the basketball team is playing in the rec gym. I can assure you that on August 20 on our campus, they're in our gym and whether it's 9:00 p.m. or 6:00 a.m., they will have appropriate coverage. That is the beauty of our guidelines. They are adaptable to these kinds of situations.

I don't have to go into much detail, but even the NCAA, in their surveys, found that the medical coverages provided for intercollegiate athletes was less than they felt was appropriate. There were not adequate emergency medical coverages for institutions. More than 50 percent of the schools in the 1998 survey had only one or two qualified medical providers on their campus. That's not enough to meet even the minimum guidelines from the NCAA.

I don't have to go into the legal implications with the Gettysburg case. There are others. I would like to tell you what we came up with. It is a system or a formula, if you will, that we tried to base on the best scientific data that is out there. There is a handout available for you. If there's not enough, I have more up here.

We withdrew all of the medical literature we could find on catastrophic data, on injury rate data for every sport. There are a lot of sports out there where the injury data is lacking. We also have a huge problem from our membership in that what we do on a day-to-day basis is the overall health care of the intercollegiate athlete. That's everything from preseason screening to post surgical care, post injury care, counseling and care of non-time loss, injury and illness. That takes up the majority of our time.

We developed a formula that's in the handout. In fact, if you wanted to go to page 8 in the handout, you'll see that what we did was take the injury rate, a catastrophic injury rate and the treatment injury rate and divided it by three to develop a base healthcare units for sports. What that is, again, is the injury rates that we could get out of the literature. We used literature from the NCAA surveillance system and the Big Ten injury surveillance system. Some conferences out there had some injury rate data that was available. We tried to combine that and come up, as best we could, with injury rates for all sports.

We looked at what we call the catastrophic injury rate. That is mostly data that came from the catastrophic work done at the University of North Carolina by Dr. Mueller. We looked at the treatment injury rate. That is the area that is the most lacking. The other two are fairly well documented from the literature. We came up with the three rates -- the injury rate equivalent, the catastrophic injury rate and the treatment injury rate. I'll come back to these. That is what we came up with base healthcare units. This isn't something we just pulled out of our heads. This is something that was started for healthcare at the Stanford Medical Center for use for another area, but we adapted to that. We decided, based on professional consensus that 12 health care units was the place to start as the work load for a health care worker in an intercollegiate setting. That's how we started with this formula.

We know there are a wide variety of differences from campus to campus. When we started to apply that, if you'll look at page 16, we took all of the NCAA sponsored sports and we listed the injury rate equivalence, the catastrophic equivalence and the treatment equivalence to come up with the base health care units for each sport.

First of all, someone might come up and say some are good and some are bad. The nice thing is that the NATA has already approved a sizeable amount of money. The first grant coming up this year is right at $200,000 to fill in the blanks where this might be a little questionable as far as documented data. This is where we came up with the basis of the formula.

We then would allow you to have a worksheet where you can then add in the various other components. As was mentioned earlier, every university and campus is different. On my campus, on a four-way stop corner, I have baseball, softball and track. We could have one health care worker cover those practices if we wanted to. We asked what was good and what's bad? We decided if you can get from one side to another side in four minutes, we felt that one person could cover them. That sounds pretty basic.

We had schools and universities come back and tell us they've got six practice sites on campus and they're all three and four miles apart. I'm lucky I have three on one corner. That takes a different set of requirements. On my campus, I may have more out of season activity than at Rhode Island College. You can adjust for that out of season activity just as we've discussed this morning.

How many athletes are we taking care of? What is the squad size? Now, we found out by looking at everything, that there are basically two sports that really have squad sizes that jump into big numbers. Basically, they were crew and football. By setting a squad size limit of 40 before you had to have additional help, you can see where more squad sizes or more than one squad can be taken care of by one health care worker.

We also had to look at other adjusted areas. Some universities require somebody to teach a half-time load. If you're teaching a half-time load, you're not providing health care coverage. Some universities require travel, extensive travel. We ran into a situation of a Division III school that had one athletics trainer, 600 athletes and that athletics trainer was off campus with one sport approximately 40 percent of the time. If you're off the campus, who is providing the care?

The nice thing about this document is that you can take it as a guide. You can sit down with your risk management, your sports medicine folks, look at it and ask where you fit into this. You can say your situation doesn't quite fit in perfectly. Between administration, sports medicine, your coach and your risk management, you should be able to come up with a plan to adapt and adjust to. Most importantly, our legal people have said it is more important in a courtroom situation that you show you have looked at the care you provide and have tried to answer the question, do we or do we not measure up and provide quality health care for our intercollegiate athletes?

The bar has been raised in health care. None of you, as administrators, expect any less out of your coaches. Your athletes expect more out of themselves. The parents expect more. Someone said to me the other day that this was not applicable to Purdue. It really is, but the bar has been raised. For example, I have seven orthopedics that work with our program. Guess what? Those seven orthopedists come out of Indianapolis, one hour away from my campus, and they probably now see 60 percent of the top-level athletes in the state of Indiana while they're in high school. The bar has been raised for health care.

The parents coming in, whether it's a Division II or Division III or Division I or a junior college school, they know exactly who the top-level health care people are in their area. We have to raise that health care with them. This is an opportunity for colleges to take and apply to their situation, see where they stand and then address the issue. That's what it is and that's all that it is.

Art Eason

Thank you. Next, we have Joan Maser, the associate athletics director from Carnegie Mellon University. Her responsibilities are, but not limited to, scheduling, coordinating travel and budgeting for the entire intercollegiate department. She has a BS in health, physical education and NATA certification from Pitt. She also has her Master's Degree in Physical Education. Prior to her assuming this position at Carnegie Mellon, she served as assistant athletics trainer, head field hockey coach and assistant athletics director. She will tell us about the financial impact and where we get the money.

Joan Maser

Thank you Art. I was asked to address this topic from an administrator's perspective. Having spent more than 10 years as an athletics trainer, I also feel comfortable looking at these issues from a trainer's eyes. There are two issues before us. One is the elimination of the intern track certification and the other is the recommendation and guidelines for appropriate medical care that Denny spoke about.

From the administrator's perspective, how will this impact your program, especially as it relates to human resources? Athletics training was a big part of my job at Carnegie Mellon for 10 years. In 1990, as my administrative duties continued to increase, we needed to make a change. The University of Pittsburgh offered us a graduate assistant who was certified if we paid the stipend. As these stipend costs continued to increase, financially it made more sense for us to move toward hiring a full-time assistant trainer, which we did this summer. We are very fortunate to have two accredited programs in Pittsburgh at Pitt and Duquesne University. We get six to 10 student trainers from these programs each year.

Every institution's situation is unique. I would like to suggest three resources that can help everyone. First, is the NATA web Site at www.nata.org. This site shows you what NATA is all about. It includes the medical coverage document. It lists the accredited programs throughout the country, as well as job placement job information.

Second, there were three articles I read recently that may be helpful. These articles are available on the following web Site, www.athleticsearch.com. You enter the search word, "NATA." Or, you can visit the Athletics Management booth here at the Convention and they can help you in obtaining these articles.

The first one is entitled The End of the Intern. It looks at how these reforms will alter the role of the student athletics trainer and professionalize the athletics trainer's image. From Interns to Students talks about NATA's new educational reforms and ways in which schools are setting up curriculum programs. Most importantly, it talks of the value of dialogue between the certified trainers and the athletics administrators to determine what needs to be done at your own institution. The third resource is your institution's certified athletics trainer.

The logical place to start is assessing your own program. The athletics trainer and athletics administrator must work together throughout this entire process. Step one is to evaluate the areas of your program that have a direct impact on the athletics trainer in doing his or her job. The number of athletes in sport, the facilities, practice and game times and sites need to be looked at. The number of practices and games, both in your traditional and nontraditional seasons, need to be looked at. Team travel schedules, particularly overnight trips should be reviewed. Availability of team physicians, training and supervision of student trainers should be looked at. What is your trainer's job description? Do they have other teaching and administrative responsibilities? Look at the athletics trainer coverage. Are they responsible for varsity sports only or do they have responsibilities for clubs, intramurals, recreation? This varies at each institution.

Here are some other factors to consider. Record keeping. Track the number and type of injuries, treatment, rehabs per sport. Where is your trainer's time being spent? Do you have an emergency action plan? Does everybody from the athletes to the coach to the athletics trainer to your campus police department know their role? Is your athletics staff trained to provide and assist when necessary?

Step two. Involve your risk management and legal offices. They are a fresh set of eyes looking at it from their perspective. How are we currently operating? What risks are acceptable? What risks aren't we willing to take? What are the financial implications? What is the insurance coverage for coaches, athletics trainers and student trainers?

Step three is your state's regulations. What is happening in your state? What, if any, are the certification or licensure requirements?

Step four, what are other institutions doing? Look at your conference schools as well as the schools in your local area. How do their athletics training programs operate? Are they doing things that can be implemented in your program?

Step five is to review the medical coverage document that you can download from the NATA web site. Take the time to read the guidelines, complete the worksheets and use the document as a resource. We did the worksheets and came up with five certified athletics trainers. Do I think Carnegie Mellon needs five? Not really. We have to ask ourselves if we're providing appropriate medical coverage with two full-time trainers who are being assisted by six to 10 student trainers from Pitt and Duquesne.

From a human resources standpoint we need to determine, not only the appropriate number of certified athletics trainers to adequately cover our sports teams, but also how to afford that second or third trainer. For many of us, hiring an additional full-time employee is not financially feasible. Some other alternatives include combining a trainer's job with other duties. It's hard to have a trainer/coach combo, but you may have an opening in administration or some other area that could be combined with a trainer's position, a part-time trainer, someone to work certain hours or certain days. We have a part-timer who helps us out on weekends when there are multiple events happening. It is our way of providing a certified trainer at all home events, especially on those busy fall weekends.

I saw two postings for an athletics training intern. Bachelor's degree, NATA certified, one-year contract, paid stipend and it could include health benefits, room and board and tuition waiver. Certified graduate assistant is similar to our arrangement with Pitt. The downside here is that you're working around the student's schedule. Local hospitals and sports medicine groups are providing certified trainers to local high schools and colleges. By subscribing to their service, you get a trainer, plus access to their physicians and rehab facilities.

Carnegie Mellon is very fortunate to have its relationship with Duquesne and Pitt. It is a win-win situation for all three schools. We get much needed help and their students get practical experience at a Division III setting.

What are the options if you don't have an accredited program in your area or you've been relying on internship track students? Work-study students with an interest in athletics could be out of season athletes. Students in medical-related fields, whether it be pre-med, physical therapy or physicians assistants programs. You may have students on campus who are EMTs that could help provide these resources. These students can help with record keeping, stocking supplies and assisting in routine tasks around the training room. If and when they gain more experience and training, they can assist the trainer in other ways such as treatment and taping. At the very least, all students should be certified in first aid and CPR.

Whether from an accredited program or recruited from within your institution, student trainers should not be a substitute for a certified trainer. We must know their capabilities and their limitations.

At Carnegie Mellon, our certified student trainers cover a lot of territory. We work between four buildings and two outside fields, not including the cross country runners that are running all over Pittsburgh. Ultimately, the certified athletics trainer is responsible for all of these athletes.

Obviously, these changes don't come for free. Budget, personnel costs are a big concern for all of us. That is why we need to assess our individual programs and come up with a plan. Changes will not happen overnight. We had used Pitt graduate assistants for 10 years. Now, finally, we are able to replace that GA with a full-time certified trainer. We worked quite a few years to get the funding for this full-time position.

Remember, there are also things that can be done which cost little or no money and will have a positive impact on your training staff. As Jerry stated earlier, coordinating practice times. On a Saturday morning, instead of having a men and women's basketball practice at 9 a.m. and 3 p.m., have them at 9:00 a.m. and 11:00 a.m., back to back. Play back to back games. On Friday night, you can have a 6:00 and 8:00 p.m. game. Coordinate medical coverage when traveling. You can send a student trainer when the host institution's certified trainer is present and reciprocate when that school comes to your place.

Clearly define the nontraditional season for each sport. What is expected of your training staff during these times? Scheduled specific times when the training room is open for training and rehabs. Look at your trainer's other responsibilities. Is there anything that can be shifted to other staff members? Improve communications either with cell phones or two-way radios.

We've all seen our athletics programs grow over the years, both in number of sports offered and in number and skill level of our athletes. The seasons have lengthened and the number of practice hours has increased. The athletics training profession has also evolved over the years from dispensing salt tablets and taping ankles to taking an athlete from an initial injury evaluation through post-surgery rehab and getting that athlete back to the playing field. The trainers are dealing with nutritional issues, strength and conditioning and other health related concerns. These are skilled health care professionals providing a valuable service to our departments.

Just look at an NATA Journal and you'll be impressed at what our athletics trainers are doing. I hope we have provided you with some ideas to take back to your campus. A panel discussion like this one that brings administrators and athletics trainers together are how the process needs to begin.

Walter Johnson

I'm Walter Johnson from North Central College. I really appreciate the discussion because I think there is a need for us to continue to review the appropriate medical care on our campuses.

One of the things you need to know, as members of Division III, is that the Committee on Competitive Safeguards has not completed its review of their appropriate health care guidelines set forth by NATA. We do expect that review to be complete within the next few months. When that is done, you will hear and have some official response from the NCAA on the document that NATA has set forth.

Art Eason

First of all, I'd like to thank the audience for coming to join us today. I know it's been a long morning and you're looking forward to our luncheon this afternoon, but you have to remember that the health and safety of our student-athletes has to be the utmost importance as we prepare to send them on to the fields. As athletics administrators, it's our responsibility to work within the resources of our institutions to try and solve this problem.

The challenge has been placed upon our shoulders and how we meet it will determine the welfare of our student-athletes. It will also determine the successes or failures of our programs and maybe even our jobs. Thank you for being here.