Simon, Lauren M.1; Rubin, Aaron L.2
The team physician may be asked to provide care for the team's athletes in the medical office, hospital, training room and, of course, on the sidelines at the sporting venue. Generally, a team will be "away" as many times as it is at home. The needs of the team on the road may be different due to issues regarding travel, location, travel related diseases, supplies and equipment, and licensing of the team physician. The goal is always the best possible care of the athlete and staff.
Sports teams ranging from age group, scholastic, collegiate, amateur, professional, and Olympic have to travel for competition and training. It is essential for medical personnel to have well-organized medical, security, and medico-legal plans in place for traveling with the team.
Most issues have been considered through the years by team physicians and the sports medicine staff. The certified athletic trainers are almost always expected to cover home and away games and can be extremely helpful in directing the team physician needs for these events. This article will not cover all the needs of the athletic training staff, but will focus on concerns of the team physician.
Ideally the travel plans should be organized well in advance of the planned travel but in some instances such as "playoffs" there may be abbreviated time for planning. However, the basic principles for traveling with the team remain the same.
Many factors need to be considered when making plans to travel with a sports team. Destination and availability of medical facilities at the sporting venue must be considered. If international travel is planned, are there special considerations regarding disease prevention that must be addressed? How many are on the travel team and how long is the trip?
The amount of resources varies if traveling with fewer players such as basketball or more players such as a football team. There will likely be additional personnel such as athletic trainers, coaches, equipment personnel, and an athletic department to be considered. The team physician's role should clearly delineate whether he/she is responsible for care of only the athletes or the rest of the athletic support personnel traveling with their team and if the physician will be responsible for any other teams at the venue.
If a youth team is traveling the team physician also needs to know what guardians or chaperones will be going and have the appropriate permission documents to treat the minors. It also is helpful to know if any of the individuals traveling with the team have medical training.
The team physician should be familiar with the medical history of the athletes and support personnel in their care and have copies of the medical histories and official consent for emergency treatment documents secured in his/her carry on luggage not in checked baggage.
Whether the team is traveling domestically or internationally the team physician needs to know what resources are available at the venues to which they are traveling. The type of emergency equipment such as automated external defibrillators (AED), spineboards, examination tables, telephones, and basic supplies such as water, ice, and towels that will be available should be determined (1,2).
For international events particularly, periodic updates to the medical plan should be made to update any medical, infectious, and security issues that may change.
No matter what setting the athletic venue is in, urban, suburban, rural, or "extreme" location it is important to know what emergency services are available such as emergency transport, paramedics, and hospitals.
In addition to knowledge of emergency transportation, advance planning is necessary to prepare for athletes that may need non-emergent medical care. For example, if a team travels to a venue by charter bus and an athlete needs medical care in the middle of the night when the bus driver may be unavailable, alternate plans should be in place for transport such as support personnel with a rental car or private vehicle. Also, if an athlete becomes injured and is unable to make the return trip home with their team there needs to be system in place to provide for that athlete.
For international travel it is important to consider not only the final destination but also the countries that the team will be stopping in en route when planning the medical, security, and immunization needs for the team. (Refer to immunizations section below.) The travel section on the Web site (www.cdc.gov/travel) of the U.S. Centers for Disease Control and Prevention (CDC) provides updated travel information by region for international travel infection risks. The U.S. Department of State's Web site (www.travel.state.gov) also provides information on travel safety and security issues.
Although contents of the team physician's medical kit for traveling with the team are listed in the Figure on the next page, sometimes the need arises for additional medication in the host country. The team physician should be aware of how to obtain medicines in the host country's medical system. Some medications that require a prescription in the United States may be available over the counter in other countries (and vice-versa). The team physician should check the regulations of the host country before carrying any controlled substances in their kit since they may be prohibited in the host country (3). According to the CDC, when traveling internationally personal prescription medication should be carried in its original container. Copies of the prescription should be carried along with the generic names for the medication and a note (preferably on letterhead stationery) from the prescribing physician. This is especially true if the individual is traveling with controlled substances or injectable medication. Local laws may impact the team physician's ability to carry prescription medications for distribution to team members. It would be helpful to include a "team pharmacist" to help with this planning and to check local pharmacy laws.
Figure. Checklist of...Image Tools
While organizing the medical plans for traveling with the team, the time of year and environmental conditions for the departure, en route, and arrival destinations need to be considered. When traveling from warmer to cooler locales or vice-versa, it is helpful to layer clothing to allow for adding or removing layers as the conditions dictate. When traveling, loose fitting, comfortable clothing is recommended as well as shoes that have room in them to accommodate dependent foot swelling that may occur during travel.
During planning for international team travel there must be adequate time allocated to obtain passports, visas, necessary medical documentation, and immunizations.
HOW WILL THE TEAM BE TRAVELING?
The mode of transportation needs to be considered when traveling with the team not only in regards to immobility and risks of deep venous thrombosis but also regarding athlete hydration and nutrition as well as location and contents of medical kits.
Whether traveling by bus, van, or airplane it is important to ensure frequent mobility to diminish the risks of venous thromboembolism. If possible, the taller athlete should sit in aisle seats or exit rows to have more legroom. Ambulation in the aisles on an hourly basis and lower extremity isometric exercises while seated should be encouraged. Travel support stockings also can be worn.
With the current Transportation Security Administration's (TSA) limits on fluids to 3 ounce containers when going through airport security checkpoints (4) (www.tsa.gov) it is important to encourage the athletes to hydrate before going through the security checkpoints and for the team personnel to arrange for adequate hydration while waiting for flights, during flights, and post travel. When flying commercially, the team management can contact the airlines in advance to request additional fluids for the athletes on board. When traveling on charter airplanes there may be more flexibility arranging for extra water and sports drinks to be available en route. Also team personnel can work with vendors (often recommended by the host venue) to provide predetermined hydration and food after arrival at their destination.
Traveling to other countries and participating in large sporting events places the athletes and the support staff at risk for both endemic diseases and outbreaks of infectious disease (5).
Before traveling, immunization status should be checked on all athletes and the support personnel. They should be up-to-date on standard vaccinations such as tetanus, diphtheria, pertussis, polio, measles, mumps, and rubella. A Varicella vaccination is recommended for anyone who has not had chicken pox or a prior varicella vaccination. Detailed vaccination recommendations are available on the CDC's Web site (www.cdc.gov) and the World Health Organization's (WHO) Web site (www.who.int). The CDC recommends a Hepatitis A vaccination when traveling to most countries of the world and the WHO recommends it for travelers to Asia, Africa, Latin America, and parts of Eastern Europe. Contact sport athletes also should receive Hepatitis B immunization. A Meningococcal vaccination should be considered since athletes may be living in close quarters. An Influenza vaccination is recommended seasonally for travelers. Other immunizations such as typhoid, Japanese encephalitis, rabies, yellow fever, etc. may be advised depending on the region(s) the athlete will visit.
Adequate timing needs to be planned for administration of the vaccines at proper intervals before traveling. For example the Hepatitis B vaccination is a three shot series given over six months whereas the varicella vaccine is a two shot series given 4 to 8 weeks apart. Travel planning also should include adequate time for athletes to recover from potential vaccine side effects, (such as a painful arm that can occur at the site of a tetanus-diphtheria vaccine), to avoid possible adverse effect on athletic performance.
With the upcoming Olympic and Paralympic games in China in 2008 many athletes and support personnel will be traveling to Asia. Throughout Asia mosquito borne illnesses such as malaria, dengue fever, and Japanese encephalitis are common. Although discussion of these diseases is outside the scope of this article the CDC's Web site provides information about these diseases and prevention.
Rabies is a big issue in China and last year was the number one reported cause of death due to infectious disease there. If the traveler has not had a pre-exposure vaccination to rabies, any mammal scratch or bite, even from a domesticated dog since few of them are vaccinated, is suspect for rabies transmission. Athletes should take care to avoid animal contact. Since international standard human rabies immunoglobulin (HRIG) is not available for post exposure therapy in China except in Hong Kong, a traveler may need to be evacuated to home or Hong Kong for post exposure treatment (3).
The CDC also lists the disease Avian influenza (currently H5N1 strain), as a health concern for those traveling to Asia. Avian Influenza, also known as "bird flu", has been found in poultry and wild birds in Asia, Europe, and Africa. The H5N1 is designated based on protein subtypes in the influenza virus (hemagglutinin and neuraminidase proteins). Although rare, human infection and death from H5N1 have been reported. The concern is that, since there is little to no natural immunity to this strain of virus, there will be a pandemic influenza outbreak if this virus begins to move from human to human. China is one of the countries that the CDC recommends individuals follow bird flu safety measures if traveling there. Some of those instructions listed include frequent hand washing with soap and water or alcohol base hand gel, avoid visiting bird farms or live bird markets, avoid touching raw poultry and eggs and seek medical care if fever with cough or sore throat or difficulty breathing develops. Visit (www.cdc.gov/travel/contentAvianFluInformation.aspx) for more information.
Traveler's diarrhea (TD) is one of the most common infections affecting those who travel (6). Forty to sixty percent of travelers to the developing world come down with diarrhea, but travelers can get diarrhea in developed countries as well. The three types of TD are "classic" (3 or more unformed stools in 24 hours along with one or more symptoms of nausea, abdominal pain, cramps, fever, or blood in stool), "moderate" (1 or 2 unformed stool in 24 hours with one of above symptoms or more than 2 unformed stools without above symptoms), or "mild" (1 or 2 unformed stools in 24 hours without additional symptoms) (7,8).
The course is usually benign and self-limited. Usually diarrhea is caused by contaminated food or water. The most common causes of TD are bacteria, (80%-85% of the cases), parasites (10%), and viruses (5%). The infection is usually self-limited in 1-4 days. The mainstay of treatment is fluid replacement. Sometimes oral antibiotics are used and rarely anti-motility agents are used.
Bismuth subsalicylate is the primary agent, other than antibiotics, for the treatment of TD. Two chewable tablets 4 times a day has been shown to reduce incidence of TD from 40% to 14% (9).
Since most cases are bacterial, empiric treatment with appropriate antibiotics could be appropriate. Indications for antibiotics would be three or more loose stools in an 8-hour period, especially if associated with nausea, vomiting, abdominal cramps, fever, or blood in stool. Antibiotics usually are given for up to 5 days. The team physician may choose to carry enough antibiotics and other treatments for travel members.
The antibiotics preferred for TD are the quinolones but they should not be used in children and there is concern about risk of tendon rupture so use in strength athletes is not advised. There also is emerging resistance to the quinolones. According to the Infectious Diseases Society of America's 2006 guidelines for travel, medicine recommended dosing includes choice of quinolones such as ciprofloxacin 500 mg twice daily for 1-3 days or norfloxacin 400 mg twice daily for 1-3 days, or levofloxacin 500 mg once daily for 1-3 days or azithromycin 1000 mg daily when not using a quinolone (10). If diarrhea does not respond to antibiotics or becomes chronic then one needs to suspect a parasitic cause of the TD such as giardiasis, amoebiasis, or cryptosporidiosis (3).
Antimotility agents, such as loperamide and diphenoxylate, reduce frequency of bowel movements and may make the traveler more comfortable and able to resume activities. These agents should generally not be used with high fever, bloody stool or in those less than 12 years old.
Fluid replacement is essential to prevent dehydration in the individual with vomiting or diarrhea. WHO has oral rehydration solution (ORS) packets available in stores and pharmacies around the world. This must be mixed in clean water in a clean container. As an alternative, 6 level teaspoonfuls of sugar and 1 level teaspoonful of salt in 1 liter of clean water could be used.
When traveling some tips to prevent TD include avoiding contact with contaminated water and food. Specifically, do not consume raw vegetables. Choose fruit that is peeled by the traveler. Avoid undercooked or raw meat or fish. Drink bottled beverages in the bottle with a straw not in a glass. Perform frequent hand washing or use alcohol based cleansing solutions on hands.
Traveling is sometimes associated with sleep disorders. When traveling rapidly across time zones individuals may get a disorder known as jet lag. Its cause is desynchrony between the body's rhythms and the environmental rhythms affecting the sleep/activity cycle. Crossing five or more time zones rapidly causes a problem with the shift of the body clock to coincide with the arrival destination environment (2). The symptoms are usually worse when traveling eastward. Symptoms include trouble sleeping at night and daytime fatigue in arrival time zone, concentration problems, headaches, bowel problems, and diminished energy, and possibly reduced performance (1,11).
Some practical opinion suggestions to reduce jet lag symptoms include setting watches to arrival destination time zone, synchronizing meals with the arrival time zone, avoiding sleep deprivation before travel and get a full nights' sleep at the new time zone (2,11,12). Time should be allotted to acclimate to the new time zone before competition but training can be done from arrival. When traveling toward the east, avoid bright lights in the mornings and get exposure to lights in the afternoons to help shift the body clock toward the new time zone.
Exogenous melatonin has been used to diminish subjective feelings of jet lag (12). It is released from the pineal gland mostly at night, is inhibited by bright light and plays a significant role in circadian rhythms (1). Athletes should only use melatonin if they have used it previously and are aware of its effects on their body. The International Federation of Sports Medicine has a position statement on air travel and performance in sports in which melatonin dosing and timing is discussed (13).
Medical supplies have been discussed in many other articles (1,14) (See Fig. 1). One of the differences when traveling is the ability to restock your medical bag. If traveling within the United States, a trip to a local pharmacy or "borrowing" supplies from the hosting team may be all that is needed. If international travel is planned, check with the home team on replacement supplies may be helpful. The team physician should be aware of how to obtain medicines in the host country's medical system from reputable clinics, hospitals, or other sites. However, avoid purchasing over the counter drugs from street pharmacies which may be selling fake or contaminated drugs (3) or have items in them that are on the world anti-doping banned substance list. The team physician should check the regulations of the host country before carrying any controlled substances in their kit since they may be prohibited in the host country.
Supplies will be limited by space as well. If traveling by air, there are restrictions on the number, size, and weight of checked and carry-on luggage. Most airlines allow 2 checked bags per passenger limited to 40 or 50 pounds per bag. United Airlines has a proposed change for May 5, 2008 limiting passengers with certain types of tickets to one bag with an additional bag charge of $25. The team physician must consider the needs for medical supplies as well as their clothing and personal supplies.
In addition, these bags must be moved from ground transportation to the airport, through the Transportation Security Administration (TSA) check point, from baggage claim at arrival to ground transportation, to the hotel room, to the venue and back at the conclusion of the event. Packing light, but being as complete as possible, becomes an art. When selecting items for the medical kit when traveling overseas to a major sporting event the team physician should assume that nothing is provided at the host venue and try to be as self sufficient as possible (2). Since this is not always possible, discussion with the athletic trainer and team officials should include the limits of care at an away venue.
The TSA has travel restrictions in place for carry-on luggage limiting liquids and creams to 3-ounce quantities displayed in a clear one-quart plastic zip top bag. Since many of the items in the team physician's bag may be of larger quantities, the medical kit will need to be put in checked baggage. The medical kit can be divided into items for carry on and items for checked baggage. With the risk of lost baggage it is prudent to carry on items that are hard to replace on short notice. A hard sided medical kit is recommended to withstand the impact of checked baggage handling. The bag must be accessible for examination by the TSA. If locked, the TSA will cut off the lock for evaluation. There are TSA approved locks that the TSA officer has a master key to open for inspection. Some of these locks have an indicator that shows the lock has been opened. One should also consider putting colored zip ties or security tags so there will be evidence that the bag has been opened, prompting an inspection and inventory of contents. International airports may have different rules that need to be observed.
The team physician should carry an itemized list of the contents of the medical kit to aid in airport screening and customs process. Careful scrutiny of the contents of the medical kit compared to the prohibited items list of the TSA should be made in advance of travel to determine what items may be placed in carry-on and checked baggage. Visit (www.tsa.gov/travelers/airtravel/prohibited/permitted-prohibited-items.shtm) for more information.
Emergencies can occur during the flight and the team physician should ensure that precautions are in place for athletes traveling with medical conditions. When traveling by airplane with a "senior" team or individuals with increased cardiovascular risk factors check with the airline to determine if there will be an automated external defibrillator (AED) on board the airplane. The on board first aid kits that the flight attendants have access to are limited and usually have only basic items and may include nonaspirin products but not actual aspirin for use in cardiovascular event. Thus the athlete and the team physician should carry aspirin on board. Similarly athletes with conditions such as food allergies who may need epinephrine should carry their epinephrine pen on board in a readily accessible location and the team physician should know where the medicine is being kept. Athletes with insulin dependent diabetes should carry sufficient medication, supplies, and nutrition on board to be prepared for unexpected travel delays.
Some common items in a sports medicine bag such as aerosol quick drying adhesive and all aerosols of more than 3 ounces are prohibited in both carry-on and checked baggage. Items that are larger than 3 ounces such as liquid medications and items such as gels or frozen liquids such as medical ice packs must be packed in checked luggage. If an injured athlete requires icing en route, carry a plastic bag and ask the flight attendant for ice. Travelers with medical conditions that may require carrying needles and syringes (such as diabetes) must present them to the security officer in front of the security checkpoint. These items will need to be separated from the other liquids, gels, and aerosols (3 ounces or less) which the traveler places in the quart-size zip top bag and will be presented for additional inspection once reaching the X-ray. Prescription medications should be carried in their original containers and the athlete should carry a note about the medical need for the prescription/medical supplies on the prescribing physician's letterhead. The person for whom the medication is prescribed should ideally carry his or her own prescriptions. To aid in inspection, it would be best to carry anything that needs to be inspected in a separate quart-size clear plastic bag.
LICENSURE AND INSURANCE
Before traveling with a team, the team physician needs to become informed about the laws governing the practice of medicine in the state or country to which he/she is traveling to avoid risk of being accused of practicing medicine without a license in those locales.
In the United States the individual state medical boards can provide information on the policies in their particular state or refer you to an appropriate place to get that information. The individual states vary on their policies.
The authors of this article practice medicine in California so the laws in California will be used as an example. If a physician who is licensed in a state other than California travels with a sports team to California that physician may treat the team members and affiliated individuals as described in the California Business & Professions Code Section 2076 (15). This law allows for a physician who has an oral or written agreement with a sports team the ability to provide general or emergency medical care to the "team members, coaching staff, and families traveling with the team" for an event in California. This is in effect for 10 days per event, but can be extended for up to 30 days with permission of the executive director of the board. This does not authorize the team physician from another state to provide care at a "health care clinic or facility, including an acute care facility."
There is a separate law that applies to physicians who will be working at the United States Olympic Training Center and Olympic Events in California (California Business & Professions Code Section 2076.5 (15)). The United States Olympic Committee (USOC) certifies the board and licensure of the physician. The practice is limited and provided to the athletes or team personnel registered to train at the training center or registered to compete at an event under the sanction of the USOC and is in effect for the length of the invitation, but no longer than 90 days.
It would be advisable for all team physicians to check state laws in states to which they will travel with their teams. If licensing exemptions are not in place, the medical staff may be practicing without appropriate licensure in the state. In addition to licensure issues the team physician needs to check with his/her insurance carrier to see if their professional liability insurance includes coverage for taking care of the team and team personnel in the state in which they practice medicine and whether they will be covered when traveling out of state or internationally. They also need to know how long the coverage will be in effect for malpractice related to the medical care provided while traveling with the team and whether they will have to purchase additional tail coverage insurance.
Careful, comprehensive planning for traveling with the team domestically or internationally can help to provide a safe experience for the athletes, the medical team, and the support personnel.