Research Experts Debate Helmet Removal - Patient Care - @

Research Experts Debate Helmet Removal

Study investigates prehospital removal of football helmets



Keith Wesley, MD, FACEP | Marshall J. Washick, BAS, NREMT-P | | Tuesday, March 22, 2011

Review Of: Swartz EE, Hernandez AE, Decoster LA, et al. Prehospital emergency removal of football helmets using two techniques. Prehosp Emerg Care. 2011;15:166–174.

The Science
This is a quasi-experimental study (doesn’t randomize subjects) comparing the different methods of removing an athletic helmet, specifically a football helmet. Thirty certified athletic trainers were tasked with removing a football helmet from two volunteers, using manual helmet removal (MHR) techniques and the Eject Helmet Removal (EHR) System. The authors compared head movement in three planes (frontal, sagittal, and transverse), as well as perceived exertion between the two methods.

The results of the study showed no statistical difference between the methods when comparing exertion. They did, however, find a difference in the length of time it takes to remove the helmet. MHR was significantly faster than EHR, and significantly less movement was recorded using the MHR technique compared with the EHR system. The authors did note that the time it took to insert the EHR device contributed to the extra time. Finally, they conclude that more research is needed to examine the use of the EHR system in the removal of other types of helmet designs.

Doc Wesley: This is the type of research EMS needs. It’s directly applicable to what we do, and it scientifically investigates one of the multitudes of new devices EMS is presented with each year. A debate continues on the proper technique for spinal immobilization, as this task is extremely complex for the helmeted victim for whom airway management is needed. I’ve seen the Eject system demonstrated and understand that it will become required in NASCAR helmets next year. My personal observation of the system echoes what the authors found: It appeared to be slower than manual removal. In this study, the authors broke Eject system time down to study both overall and helmet removal (assuming bladder already installed) and found that removal still took on average 11 seconds compared to 6 seconds with the manual technique.

An interesting aspect of this study is its measurement of head motion. This is somewhat difficult to interpret because no quantifiable correlation between head and cervical spine motion is mentioned. It’s accepted that less motion is preferred, but how much motion is deleterious? Simply because the Eject method resulted in more motion doesn’t necessarily indicate that spinal motion would have been clinically significant.

My final observation is that this was a study (as the authors admit) of only one type of helmet. The full-face-mask helmet used in other sports, particularly in motocross, presents significantly greater challenges, so a study of this system with that type of helmet would be extremely enlightening.

Medic Marshall: I agree with the Doc on this one: This is exactly the type of research EMS needs. Each year, companies, aspiring entrepreneurs and inventors go out and promote their equipment and devices as the “latest and greatest” that will answer our problems, removing helmets in a safe and efficient manner, in this case. I’m sorry to say that not every device created (no matter how novel) is the answer. Even if the person trying to sell you the device says it’s supported by research, that doesn’t mean it’s the answer. This brings me to my next point: the importance of research and understanding it.

I, too, have seen this Eject system at various conferences being promoted as the alternative to removing helmets instead of using manual techniques. But this study seems to demonstrate that the manual technique is superior, albeit in football helmets. So when you find yourself at the next EMS conference and you’re walking up and down the vendor isles examining the new gizmos and gadgets that are going to make your life easier on the streets, stop and ask for the research or literature and ask them to explain how their device (based on said research and literature) is better than the current practices.

Objective: To compare the Eject Helmet Removal (EHR) System with manual football helmet removal.

Methods: This quasi-experimental counterbalanced study was conducted in a controlled laboratory setting. Thirty certified athletic trainers (17 men and 13 women; mean °æ standard deviation age: 33.03 °æ 10.02 years; height: 174.53 °æ 12.04 cm; mass: 85.19 °æ 19.84 kg) participated after providing informed consent. Participants removed a Riddell Revolution IQ football helmet from a healthy model two times each under two conditions: manual helmet removal (MHR) and removal with the EHR system. A six-camera, three-dimensional motion capture system was used to record range of motion (ROM) of the head. A digital stopwatch was used to time trials and to record a split time associated with EHR system bladder insertion. A modified Borg CR10 scale was used to measure the rating of perceived exertion (RPE). Mean values were created for each variable. Three pair-wise t-tests with Bonferroni-corrected alpha levels tested for differences between time for removal, split time and RPE. A 2 °ø 3 (condition °ø plane) totally within-subjects repeated-measures design analysis of variance (ANOVA) tested for differences in head ROM between the sagittal, frontal, and transverse planes. Analyses were performed using SPSS (version 18.0) (alpha = 0.05).

Results: There was no statistically significant difference in perceived difficulty between EHR (RPE = 2.73) and MHR (RPE = 2.55) (t29 = 0.76; p = 0.45; d = 0.20). Manual helmet removal was, on average, 28.95 seconds faster than EHR (t29 = 11.44; p < 0.001). Head ROM was greater during EHR compared with MHR in the sagittal (t29 = 4.57; p < 0.001), frontal (t29 = 5.90; p < 0.001), and transverse (t29 = 8.34; p < 0.001) planes. Head ROM was also greater during the helmet removal portion of EHR in the frontal (t29 = 4.44; p < 0.001) and transverse (t29 = 5.99; p < 0.001) planes, compared with MHR. Regardless of technique, sagittal-plane head ROM was greater than frontal- and transverse-plane movements (F2,58 = 241.47; p < 0.001).

Conclusions: Removing a helmet manually is faster and creates slightly less motion than removing a helmet using the Eject system. Both techniques were equally easy to use. Future research should analyze the performance of the Eject system in other styles of football helmets
and in helmets used in other sports such as lacrosse, motorsports and ice hockey.


Connect: Have a thought or feedback about this? Add your comment now
Related Topics: Patient Care, Street Science, MHR, Marshall Washick, manual helmet removal, Keith Wesley, helmet, eject helmet removal, EHR

Author Thumb

Keith Wesley, MD, FACEP

Keith Wesley, MD, FACEP, is the Minnesota State EMS medical director and the EMS medical director for HealthEast Ambulance in St. Paul, Minn. and and can be reached at


Author Thumb

Marshall J. Washick, BAS, NREMT-Pis a paramedic and the peer-review/research coordinator for HealthEast Medical Transportation. He can be contacted at


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