It’s “Friday Night Lights” and you’re sitting in the stands at your local high school when you see the star running back take a helmet-to-helmet hit. He now lays motionless on the ground surrounded by coaches and teammates. Everyone frantically looks around searching for the ambulance—but it’s not there.
The sad truth is no state currently requires an ambulance be present during regular season high school football games.1 The cost, schools say, is prohibitive. However, the need for EMS at high school football games has never been greater.
According to the National Federation of State High School Associations (NFHS), there are approximately 1.1 million high school athletes playing football in the United States each year. High school athletes account for an estimated 2 million injuries, 500,000 doctor visits and 30,000 hospitalizations annually.2 According to the National Center for Catastrophic Sports Injury Research, 11 high school athletes died as a result of injuries sustained during a football game in 2014.3 Of these, five were “direct fatalities.” Of the direct fatalities, 83.3% were brain injuries and 16.7% were cervical fractures. There were also six “indirect fatalities” of high school football players in 2014. Three of these were heart-related, one was heat stroke and two were hypernatremia/water intoxication.
Although the rate of direct fatalities of high school football players for 2014 was low at 0.45 per 100,000 participants, almost all of these fatalities occurred during games. This is significant, because there are five times as many practices as there are games each week. Further, a recent report by The National Academy of Medicine (NAM) found that high school football players were twice as likely to suffer a concussion than a collegiate player, and the incidence of reported concussions of high school football players had doubled between 2008 and 2012. According to the Centers for Disease Control and Prevention (CDC), the incidence rate for traumatic brain injuries for high school football players is 0.47 per 1,000 athletes.4 So, given this evidence, why are high schools not required to have EMS attend football games?
The simple truth is that while regulations to make football safer have increased in recent years, there has been no corollary push to require high schools to hire EMS to attend football games. Over the last decade, sports governing bodies have adopted new or modified existing rules to reduce head and neck injuries, protect defenseless players, remove targeting from the game and require return-to-play (RTP) protocols for suspected concussed players. Washington became the first state in 2009 to pass legislation requiring football players under the age of 18 who are suspected of having a concussion to be removed from practice or a game and not allowed to return to play until cleared by a medical professional. Currently, all 50 states and the District of Columbia have some form of concussion safety laws. Last year California passed a statute requiring any middle school, high school district, charter school or private school that elects to offer athletic programs to immediately remove from practice or competition any athlete suspected of sustaining a concussion. The law further mandates an RTP protocol of no less than seven days when a licensed healthcare provider determines that the athlete has sustained a concussion or head injury. The statute defines a licensed healthcare provider as “a licensed healthcare provider who is trained in the management of concussions and is acting within the scope of his or her practice.”5 Although the California legislature is vague on defining which medical professionals can clear a concussed athlete to return to play, the California Interscholastic Federation (CIF) adopted a new rule in 2015 which limits such clearance to a medical doctor or doctor of osteopathy.6
Pop Warner, the largest youth football organization in the world, requires the home team to provide medical coverage at each game. “In the absence of a physician and or ambulance on site, the minimum safety requirement will be the presence of an individual associated with the home team/host organization who is currently EMT qualified or certified in Red Cross Community First Aid and Safety, the P.R.E.P.A.R.E. Course by the National Center for Sport Safety, or their equivalent.”7 Not surprisingly, there were no fatalities reported in 2014 for Pop Warner football players.3
With limited economic resources available to provide adequate medical staffing, many high schools rely on volunteer physicians to attend their football games. A physician who practices at a sporting event free of charge is often referred to as a “volunteer event physician.”8 A volunteer event physician donates his or her time and expertise without accepting payment or expecting any monetary gain or remuneration for providing these services. Typically, these volunteer event physicians make the following four mistaken assumptions about their legal liability when volunteering to be a sideline doctor: 1) Good Samaritan laws will protect them from potential legal liability; 2) the school’s general liability insurance will cover them as insureds; 3) the physician’s own professional liability policy will insure them against legal liabilities for volunteering at events; and 4) release of liability waivers signed by the athletes and their parents as a prerequisite to participating in school-sponsored athletic events will exempt the physician from liability.
Good Samaritan laws were not written to protect a volunteer physician from liability against a claim of medical malpractice occurring at a high school football game. This is because many states’ Good Samaritan laws do not apply to non-emergent care, such as treating a laceration, sprains or strains, or simple fractures. Most Good Samaritan laws were written to encourage the rendering of emergency medical care at the scene of a motor vehicle accident or other emergency. For instance, the Supreme Court of California interpreted its Good Samaritan law to only immunize a volunteer from liability when that person renders emergency medical care at the scene of an emergency. The court ruled that a civilian who pulled an injured driver out of his vehicle was not engaged in rendering “emergency medical care” and thus not immune from the driver’s subsequent lawsuit for his resulting permanent paralysis.
Further, only law enforcement, firefighters, EMTs, EMT-Ps and registered nurses are provided a qualified immunity from civil liability for voluntarily rendering emergency medical care at the scene of an emergency.9 Thus, a doctor who volunteers his or her time to be a sideline physician would fall outside of California’s statutory immunity protection afforded to EMS members. By contrast, Arizona,10 Kansas,11 Minnesota12 and Virginia13 all have passed legislation providing a qualified immunity to healthcare professionals who volunteer at amateur sporting events, provided they act in good faith and without gross negligence. Thus, knowledge of local statutes is important.
The volunteer event physician likely will not have coverage under the school’s liability policy, because such policies typically exclude professional liability. Likewise, the volunteer physician’s own professional liability policy may exclude coverage for medical care provided on a voluntary basis outside of hospital or medical office setting.
Finally, courts generally will not uphold the validity of a patient’s release of a physician’s liability on the basis that such a release is against public policy. Thus, a waiver of liability signed by an athlete and/or the athlete’s parents releasing the school from liability as a prerequisite to participation in athletics will not immunize the volunteer physician from liability.
Thus, relying upon physicians to volunteer their skills and risk their personal liability to be on the sidelines of high school football games is clearly not the answer to fill this critical need. Legislation is needed to require high schools to contract with qualified EMS providers to attend their football games and provide emergency medical care in the pre-hospital setting.
1. Gregory S. (Oct. 2, 2014) Another high school football player dies after injury. TIME. Retrieved on Jan. 20, 2016, from http://time.com/3457700/another-high-school-football-player-dies-after-injury/.
2. Centers for Disease Control. (Sep. 29, 2006) Sports-related injuries among high school athletes—United States, 2005–06 school year. Morbidity and Mortality Weekly Report (MMWR). Retrieved on Jan. 20, 2016, from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5538a1.htm.
3. National Center for Catastrophic Sports Injury Research. (March 2015) Annual survey of football injury research. University of North Carolina at Chapel Hill. Retrieved on Jan. 20, 2016, from https://nccsir.unc.edu/files/2013/10/Annual-Football-2014-Fatalities-Final.pdf.
4. Gessel L., Fields S., Collins C., et al. Concussion rates among U.S. high school and collegiate athletes. Journal of Athletic Training. 2007;42(4):495–503.
5. California Education Code §49475.
6. CIF Blue Book Rule 503 (2015).
7. Pop Warner. (2015) Pop Warner concussion policy. Retrieved on Jan. 20, 2016, from www.popwarner.com/safety/concussionpolicy.htm.
8. Ross D., Ferguson A., Herbert D., et al. Action in the event tent! Medical-legal issues facing the volunteer event physician. Sports Health. 2013;5(4):340–345.
9. California Health & Safety Code §1799.106(a).
10. Arizona Revised Statute §32-1472.
11. Kansas Statute §65-2891.
12. Minnesota Statute §604A.11.
13. Virginia Code 8.01-225.1.