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INVITED COMMENTARY

Be Prepared

What's in Your Game Bag?

Hutchinson, Mark R. MD; Briner, William MD

Author Information
Current Sports Medicine Reports: February 2007 - Volume 6 - Issue 1 - p 5-10
doi: 10.1097/01.CSMR.0000306549.96216.1b
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Introduction

Whether you have assisted in the care of 1000 events or next weekend's competition is your first step onto the field of event coverage, you should be asking yourself, “Am I prepared?” According to the consensus statement developed by key supervisory organizations regarding sideline preparedness for the team physician, sideline preparedness is the identification of and planning for medical services to promote the safety of the athlete, to limit injury, and to provide medical care at the site of practice or competition. This preparedness includes pre-event planning, which involves arranging for appropriate staffing, equipment, and materials; prescreening athletes for safe participation; as well as creating an emergency plan for all possible contingencies of injuries. This commentary focuses on your personal preparedness for the event and, specifically, provides some suggestions regarding how to make sure your game bag is ready to assist you in being a great event physician.

In ancient American Indian societies, the medicine man traveled with a pouch filled with various herbs that he would use when called upon to treat an injured or ill member of the tribe. In the early modern era, the community doctor would make house calls carrying with him a doctor's bag filled with diagnostic equipment (eg, a stethoscope, reflex hammer, glass syringes), and therapeutic bandages and medications (eg, laudanum or an opiate derivative for pain, digitalis leaves or pills for heart ailments). These early “event bags” account for the basic principles that are the foundations regarding what should be in our game bags today: preparedness as well as versatility and readiness.

This guiding principle is also a foundation of the Boy Scouts of America: Be Prepared. Your game bag should be adequate for the population or specific sport you intend to serve and the type of injuries that you will likely encounter. It should also be adequate for the total number of athletes for whom you are responsible and account for what materials may already be available at large events (Table 1). For example, marathon planners should already have arranged treatment areas, cots, cooling stations, fluid management, including intravenous (IV) bags and tubing, thermometers, and electrolyte testing equipment. In this scenario, your personal game bag would not be expected to supply all of this equipment.

T1-4
Table 1:
Routine pre-event questions for all events

Admittedly, game bags tend to be very individualized, with physicians developing personal preferences for what works for them and/or carrying additional supplies due to the demands of the specific sports or events they are covering. When covering distance running events you are more likely to see hydration problems and blisters. Carrying additional IV fluid sets and blister treatment and prevention materials would be wise. Collision sports tend to have more traumatic injuries; therefore, carrying additional splinting materials or suture sets to repair lacerations would be prudent. Knowledge of the unique sport-specific injury risks in the event you are covering is essential for pre-event planning. Unique equipment in your game bag may also vary with individual training and experience. When I have the opportunity to share coverage with a colleague, I will commonly peek in his or her bag to pick up new and helpful hints.

Optimizing your personal preparedness prior to an event should include a quick review of the contents of your personal game bag, the specific location of materials, an assessment that all of the contents are present or have been replenished since its last use, and an evaluation of any supplies that can expire or lose their function. I will usually place urgent materials for the specific sport in the most accessible location. For example, when covering hockey, I will have a suture set including skin preparations, anesthetic, and sutures right on top and ready to go. All medications should be checked for expiration dates on a routine basis. I check mine twice a year with season changes. Diagnostic tools and batteries should be checked for function prior to each event. You do not want to learn that the flashlight and cell phone are out of charge just when you need them.

A complementary principle to preparedness when creating a functional game bag is versatility and readiness. For the team physician who cares for a number of sports, the game bag should be tailored to the injury patterns in each sport. This versatility may come at a price as you may need a larger bag to carry a greater variety of equipment and volume of materials. Many physicians have a large game bag for such purposes and complement it with a smaller bag or fanny pack to keep essential materials with them at all times. My fanny pack usually holds gloves, bandages, gauze, tape, sterile would-closure strips, Monsel's solution, nasal pledgets, an albuterol inhaler, acetaminophen, and an epinephrine pen.

Game bags come in all shapes and sizes to fulfill the unique demands of each individual and competition. Larger bags with built-in rollers ease transport from event to event. The best game bags have a durable exterior and multiple pockets or separations that allow compartmentalization of the various medical needs. For the optimal sideline management of injuries, readiness is key. This readiness is an outgrowth of organization and planning. If at the time of an emergency you have to scramble through an unorganized mess to locate your needed tool or material, you will be wasting valuable time and appear disorganized to the athlete and those around him. Readiness can be optimized by organizing and laying out your game bag in advance. This is the great advantage of multicompartment bags. You can dedicate a certain pocket or compartment to a defined role that, in turn, makes its items easy to find. Sections, pockets, or compartments in your game bag can be earmarked for wound and laceration care; hydration and fluid management; bone and joint injuries; head, ear, eye, and nose injuries; cardiopulmonary, medications; and diagnostic tools. In my bag, the most readily available locations are reserved for wound care and lacerations as well as cardiopulmonary. Table 2 includes a listing of what goes into my game bag by compartments, with some commentary regarding specific materials.

T2A-4
Table 2:
Contents of game bag
T2B-4
Table 2:
Contents of game bag (Continued)

One such bag that comes with compartments is a fishing tackle box. Many team physicians elect to use a tackle box as their game bag. An added benefit is that these are also fairly impervious to the elements at outdoor competitions. Another option for the team physician bag is a roller bag, which may be more practical for covering a large team for which air travel is involved. Even though the physician may wish to keep his or her bag handy at all times, and feel uncomfortable letting it out of sight, this bag will almost always have to be checked because of its contents. Within the roller bag, smaller individual bags can be utilized as the compartments listed above. Clear plastic cosmetic-type bags are ideal for this purpose. These can then be labeled for quick identification.

Wound Care and Lacerations

This region of the game bag is one of the most important as it provides the team physician the greatest opportunity to affect the outcome of the game itself. When you can control bleeding, prevent risk of contamination of opponents, and repair a laceration in a time-efficient fashion, then you may assist in getting a key player back on the field. This compartment should be readily accessible with easy access to irrigation, antiseptic cleansing agents, drapes, suture set, appropriate suture, anesthetic, syringes, and needles. For my game bag, I simply open the lid and I am ready to go (Table 2, section 1A). An additional adjacent compartment is a good location for general wound care, adhesive bandages, dressings, and bandages (Table 2, section 1B).

Cardiopulmonary Care

Although wound care and lacerations may be the most likely chance for you to have game-related impact on outcomes, perhaps the most important section for life-saving impact is the cardiopulmonary compartment. This section should be readily available to impact on urgent airway, cardiac, or breathing issues. For the most basic of game bags this should include a pocket mask, oral airways, a bulb syringe for suction, paper bags for hyperventilation, large gauge angiocatheters that can serve to treat pneumothorax or serve as stint to buy time as a needle cricothyrotomy (Table 2, section 2), Minimal medications should include an albuterol inhaler and an epinephrine pen. The presence of an automatic defibrillator (AED) on site is becoming standard and I believe as their size continues to get smaller they will be found commonly within the game bag of the team physician. Currently, our athletic trainer carries one to each event. For helmeted events, either the trainer or I will carry necessary equipment to remove the facemask in emergency situations.

Regarding more advanced cardiopulmonary medications, one must assess if paramedics or advanced trained emergency personnel will be available on-site, obviating the need for you to have them in your game bag. The highest chance of salvage of a patient with a cardiopulmonary event is basic cardiopulmonary resuscitation with appropriate use of an AED followed by urgent transport to an emergency medical facility. Initiating advanced cardiac life support (ACLS) on site only delays time to get to the emergency facility. If you are currently up to date with your ACLS, it is clearly your option to maintain recommended medications in your game bag. It is imperative that these are routinely checked for outdates and that their use is performed within recognized ACLS protocols. If you elect not to carry ACLS medications (and even if you do) it is essential to assess the emergency plan before every game.

Diagnostic Tools

The diagnostic compartment contains the all the necessary equipment to make common diagnoses (Table 2, section 3). Many of these tools, such as a flashlight, otoscope/ophthalmoscope, and glucometer, require batteries, which introduces the responsibility to assess their function prior to the event. Carrying extra batteries is most helpful to prevent them from dying when you want them most. Try to search out devices that use conventional batteries as these are more readily available anywhere in the world. Many diagnostic devices can be modified from simple readily available materials that are compact, lightweight, and easily carried in the game bag. Paperclips make great two-point discriminators. Safety pins are wonderful disposable devices for sharp-dull discrimination. A tuning fork is not only a great tool to assess vibratory sensation, but it doubles nicely as an assessment for stress fractures.

Hydration and Fluid Management

The fluid management compartment includes all materials to begin IV hydration: rubber tubing as a temporary tourniquet; antibiotic/microbicide swabs to prepare the skin; 16-, 18-, and 20-gauge angiocatheters (larger bore preferred for quicker hydration); IV tubing; and adhesive bandages and tape to secure the IV in place. A clear sterile intravenous dressing is usually most practical. There has been some debate regarding the optimal solution (lactated Ringer's, D5 normal saline, D5 1/2 normal saline, D5 1/3 normal saline for children, and normal saline). Current recommendations in most dehydration situations are to begin with normal saline. Two liters of normal saline is enough to get started in treating the hypovolemic athlete. This won't take up too much space or be terribly heavy (Table 2, section 4).

Head, Ear, Eye, Nose, and Dental Care

The next two regions of the game bag are the specialty compartments. These may be individualized base on the physician's skills but should always account for common injuries in sports. The first of the specialty compartments is dedicated to problems of the head, ears, eyes, nose, and throat. Common problems of the eye include foreign bodies, scratched corneas, contact problems, and pink eye. Common problems of the ear include soft tissue injuries such as cauliflower ear, ruptured eardrums, infection, or inflammation.

Common problems of the nose include nose bleeds and broken noses. Common problems of the mouth include lip and tongue lacerations and chipped or avulsed teeth. A properly equipped game bag should account for these common problems in athletes (Table 2, section 5).

Musculoskeletal Care

The second specialty region of importance is dedicated to the musculoskeletal system. Plastic and foam-laminated aluminum splints are lightweight and can slide onto the flat side or outer pocket of a game bag. The foam-laminated aluminum has the added advantage of flexibility to account for virtually any injury of the hand, fingers, or toes. I also carry two to three rolls of fiberglass with accompanying cast padding that will allow me to temporarily splint virtually any body part. Paper clips and a lighter or a sterile needle may also come in handy to decompress an athlete with a painful subungual hematoma (Table 2, section 6).

Miscellaneous

Dedicated to the principle of versatility and preparedness is the compartment labeled “miscellaneous” (Table 2, section 7). This compartment of the game bag contains equipment that is not well defined in the other compartments but clearly is important to the effective care of athletes and the ability to be ready for as many challenges as possible. Admittedly, some items listed here may be stored just as well as in other compartments. For example, scalpels and a sharps box or contamination bag may appropriately be stored with the laceration kit and wound care. Wet wipes or hand cleansers should also be readily available for all interventions. Either in the miscellaneous compartment or with the diagnostic tools consider carrying bandage scissors, a multipurpose knife, a small multiheaded screwdriver, a utility tool that includes pliers, and nail clippers. In addition to the variety of medical tape, I also include a small roll of duct tape in honor of my grandfather who told me he could fix anything with duct tape (you would be surprised by how many game-side equipment failures you can repair). Finally, this pocket includes chemical cold packs and various materials for “communications” including a cell phone (sometimes the most important item in the bag), prescription pads, pens and paper, and business cards. When you care for athletes from the other team, your business card is a great way for their treating doctor to follow-up with you as needed.

Game Bag Formulary

Beyond the miscellaneous compartment, one of the most variable areas when comparing game bags and the team physicians that carry them is what should be included on the game bag formulary. As in medical practice, there will be certain medications physicians prefer and some they don't. This commentary is not intended to tell you specifically what brand or what medicines to carry but rather to help you consider the issues regarding the formulary you choose. One hint: when given the options of pills versus liquids, take the pills because they travel easier. The choice of medications like every other aspect of the game bag will depend on the population you serve and where the location of the event is held. If the site is within your country, then you can minimize what you carry assuming that a simple prescription will fill in the gaps. If you are traveling internationally with a team, you may need to be prepared for a myriad of potential problems including but not limited to: pain management, gastrointestinal disorders (diarrhea, constipation, nausea), infectious processes (flu-like symptoms, skin infections, conjunctivitis, sore throats, runny noses, coughs), insomnia or difficulty adjusting to jet lag, allergies, and asthma (more common in polluted cities; Table 2, section 8). The key comes back to the first principle of our game bag design: be prepared.

When selecting medications to address the problems you are likely to face, you should also be attentive to the athletes being served. For large groups of athletes, you may need to bring more supplies. You should also be keenly aware of banned substances within the competition at hand. Olympic athletes have been stripped of their medals based on the innocent error of a treating physician offering an athlete a banned substance. Most athletes assume that you know these rules and will take what is offered to them. I carry with me the current guidelines from the United States Anti-Doping Agency (USADA) and check it prior to distribution. Many of these substances change from year to year and, if there is a question, you should check before dispensing. The USADA drug reference line is 1-800-233-0393 or you can check on the Internet at http:\\www.usantidoping.org or at http:\\www.WADA.org. It is also a good idea to separate known accepted drugs from banned drugs or consider not even carrying banned drugs. When traveling internationally, you should also maintain a list of all medications that you are carrying and place a copy in the bag and keep another with you. This may help as you pass through customs.

Conclusions

When creating a game bag, the guiding principle must always to be prepared for as many of the potential injuries and problems as possible. This preparedness begins with an understanding of the demands of the event you are covering and the type of problems you may face. It includes pre-event planning regarding understanding the emergency plan and what materials will already be available for you. The versatility and readiness of your personal game bag will assist you in achieving optimum preparedness. A well-organized, compartmentalized, well-maintained, and frequently reviewed game bag will give you the confidence to address most problems you will encounter on the sidelines of the playing fields you cover. Good luck.

Recommended Reading

1. Team physician consensus statement.Med Sci Sports Exerc 2000, 32:877–878.
    2. Mellion MB, Walsh WM, Madden C, et al.: Team Physician's Handbook, edn 3. Philadelphia: Hanley & Belfus; 2002:7–8.
      3. Sideline Preparedness for the Team Physician: Consensus Statement. American Orthopaedic Society for Sports Medicine, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American Medical Society for Sports Medicine and the American Osteopathic Academy of Sports Medicine. Available at http://www.aaos.org/wordhtml/papers/advistmt/1022.htm. Accessed November 14, 2006.
        4. Rubin A: Sports Injuries and Emergencies: A Quick Response Manual. New York: McGraw Hill; 2003.
          5. Martinez JM: Medical coverage of cycling events.Curr Sports Med Rep 2006, 5:125–130.
            6. Howe WB: What I take to the game.Physician Sportsmed 1990, 18:61–66.
              © 2007 American College of Sports Medicine