Evidence-Based Medicine and the Recognition and Treatment of Exertional Heat Stroke, Part II: A Perspective From the Clinical Athletic Trainer

Study Design

Maxwell21 described qualitative research as especially suited for gaining understanding and meaning, identifying critical influences, and, consequently, generating theory about those influences and experiences. In our study, we wanted to capitalize on this concept and develop a theory to explicate why a disconnect exists between actual practice and the recommendations of the NATA regarding recognition and treatment of EHS.120 In-person focus group sessions were used to gain insight because they have been demonstrated to provide rich data through interactions of group members, in which one person's response can stimulate further discussion.22 This method is most beneficial when the purpose of the research is to dig deeper into a specific topic area. We wanted to use previously obtained data to further uncover attitudes and beliefs and to provide specific examples of a particular experience encountered by the sample population.2324 Before focus group sessions were conducted, each participant was instructed to complete a background questionnaire to document demographic information and experiences with EHS. The questions assessing the participant's knowledge of and experiences with EHS were scored using a Likert scale. Each question associated with a Likert scale involved the participant's comfort or familiarity with certain factors involved in EHS, and each scale was numbered from 1 to 10, with 1 indicating not comfortable or not familiar and 10 indicating very comfortable or very familiar (Appendix 1). The participants were not given any more information about the scale.

Participants

All participants were recruited at the 2009 Annual Meeting of the NATA, held in San Antonio, Texas, using a convenience and snowball sampling technique.21–23 Participants consisted of 19 ATs working in the HS (n = 9) or collegiate (n = 10) setting (Table 1). They were separated into 5 focus groups: 2 groups of HS ATs and 3 groups of collegiate ATs (focus group 1 included 3 participants; focus group 2, 4; focus group 3, 3; focus group 4, 6; and focus group 5, 3). All participants were enrolled based on predetermined criteria, including current Board certification for at least 5 years and employment in one of the aforementioned clinical settings. Participants represented NATA districts 1, 2, 3, 6, 7, and 8. All participants provided written informed consent, and the University of Connecticut Institutional Review Board approved the study.

Table 1. Demographic Information of the Participants (Mean ± SD)

View Fullscreen

Procedures

Pilot testing was conducted with a small group of collegiate ATs before data collection to help with focus group facilitation and clarity of the interview guide, which was developed by a panel of athletic training professionals and experts in the areas of heat illness and qualitative methods. After reviewing the pilot test, we made small modifications to the interview guide, including grammatical changes for readability and ordering of questions for more effective flow (Appendix 2). Four focus group sessions were conducted in person at the 2009 Annual Meeting of the NATA in San Antonio, Texas. One focus group interview with collegiate ATs was not held in this setting because of scheduling conflicts and unexpected meetings at the conference. This group of ATs, who lived near each other, agreed to participate in a separate focus group session at a neutral conference room after the convention. Each focus group session included a 2-member research team: a moderator (B.P.M.) and a person taking field notes (D.E.P.). The focus group sessions were structured and followed the interview guide (Appendix 2). Interview guides were meant to guide discussion on the topic of EHS and not to interrogate participants about their practice beliefs. The interview guide was configured to focus on ATs' knowledge and practice beliefs regarding recognition and treatment of EHS. All focus group sessions were recorded on audiotape and video to ensure accuracy in transcription. All 5 focus group sessions were transcribed verbatim, and all participants were assigned pseudonyms to ensure confidentiality. After initial transcription and before data analysis, the participants reviewed the transcripts from the focus group interviews to clarify statements they made. We selected member checking, multiple-analyst data triangulation, and data triangulation to establish trustworthiness of our data.2223 Data triangulation was ascertained by interviewing both collegiate and HS ATs, and multiple-analyst data triangulation proceeded as described later.22

Data Analysis

Interview transcripts were analyzed using open coding in data analysis as described by the grounded theory approach to qualitative research.2325 During this process, the analysis was guided by the overall purpose and research questions of the study. Two researchers (S.M.M., B.P.M.) independently reviewed the transcripts line by line to identify commonalities; this step was used to ensure accuracy and reduce researcher bias during data interpretation.23 After emerging themes were identified, conceptual tags were given to capture their meanings. Next, researchers used a more selective coding process to highlight the core concepts and make connections among the emerging themes regarding the lack of implementation of evidence-based practice (EBP). After final themes were identified using the grounded theory approach, the 2 researchers shared findings to ensure consistency in analysis. When this was complete and when the researchers had reached agreement, the final themes and visual model were shared with the research team.

Lack of Knowledge

Lack of knowledge about EHS began initially in the participants' undergraduate AT experiences and continued to mount throughout their professional careers. Comments such as “If you use immersion [to treat an athlete with EHS] they'll go into shock,” “I'd take a tympanic temperature if we had time [to determine core body temperature],” and “They will stop sweating [if they have EHS]” were common during focus group sessions. Several comments also were similar to those of Sally, who said, “There is going to have to be something specific datawise to say that we should measure it [rectal temperature],” demonstrating that participants do not remain informed of the most current research and the NATA's position statements or that they believe the device is not necessary. Incorrect knowledge and not staying informed about the literature on EHS perpetuated an AT's failure to implement EBP regarding EHS.

Comfort Level

Throughout the focus group discussions and regardless of clinical setting, we found that ATs were uncomfortable with various aspects associated with the recognition and treatment of EHS. This theory of comfort level was reinforced by participants' responses to the series of questions asked before focus group sessions, in which they rated their levels of comfort on a 10-point Likert scale ranging from 1 (not comfortable) to 10 (very comfortable). Table 2 provides a summary of these responses. Kyle, a collegiate AT, said, “It has to do with the squeamishness that most of us have with sticking a thermometer up somebody's butt.” Sally, an HS AT, mirrored Kyle's viewpoint: “We're dealing with minors, you know.” Commonly, the ATs discussed discomfort with the NATA position statement on EHI,8 including using Tre and CWI (Table 2). The most common factor contributing to a lack of comfort with the skills associated with recognition and management of EHS was a lack of training. Many participants reflected that, during their academic preparation, skill instruction regarding T_re and CWI was limited and not covered as in depth as other concepts, such as evaluating the ankle or learning cardiopulmonary resuscitation. In addition, many participants thought they had limited exposure to actual cases of EHS. This lack of preparation and real-life exposure limited an AT's level of comfort using T_re and CWI when addressing EHS. Linda explained, “Part of the reason that we don't use [rectal temperature devices] is because we were never trained on how to use it [during entry-level education].” Many of the ATs at the HS level expressed concern because their athletes are still children. Sue said, “I'm not taking a rectal temperature unless I absolutely have to, and with a[n] HS athlete it's just too close for comfort.” Insufficient comfort level was a major theme expressed in both groups. For this group of ATs, a lack of training during their academic preparation and exposure to actual cases of EHS contributed to feelings of discomfort with implementation of recommended practices.

Table 2. Familiarity and Comfort With Different Aspects of Addressing Exertional Heat Stroke (Mean ± SD)

View Fullscreen

Lack of Initiative

Lack of initiative was operationalized as minimal initiative to make changes to their emergency action plans or their policies and procedures or as time constraints in daily work-loads. Both collegiate and HS ATs struggled with this in different ways (Figures 2 and 3). Collegiate AT Frank said, “It's hard to make changes until something happens, where it affects someone, and they see they need to make the change.” High school AT Scott said, “It's not worth changing anything if it's been very successful and we haven't had any problems with it.” Some participants expressed concerns about the daily effort (eg, setup, cleaning), the time it would take before and after each practice, and the type of supplies necessary to set up and break down a CWI tub as reasons they currently did not use it. Bob explained, “We don't have [CWI] because of the setup and breakdown every day.” Another AT echoed Bob's concern: “Yeah, we don't have it, but like [Bob] said, because of the setup and breakdown every day.” Overall, a lack of initiative and time to make changes based on current research was seen across both collegiate and HS settings.

Liability Concerns

Liability concerns were a common barrier to implementation of EBP for HS ATs, primarily because of the ages of the athletes (Figure 3). The liability issues were focused mostly on T_re rather than CWI primarily because the technique is viewed as invasive and a breach of the patient's privacy. When discussing why she does not obtain rectal temperature, Sue said, “It's a kid, you know. I've heard of athletic trainers getting sued for looking at a groin because it was [seen as a] sexual advance [rather than an evaluation of an injury]. I really don't want to put my license on the line for that.” Joe said, “To use the rectal temperature, I would have to do it without their consent. I don't need to do it; I'm calling 9-1-1.” The role of sex was also a concern regarding the legality of obtaining rectal temperature, in which a male or female AT would obtain a measurement in a minor of the other sex.

Lack of Resources

For HS ATs, a lack of equipment and resources created apprehension about implementation of appropriate measures. In several instances, HS ATs discussed not having the budget for the expenses associated with T_re or CWI. When asked whether they had T_re available as one of their temperature assessments, 4 HS ATs responded, “No,” and the rest said they had thermometers that could be used rectally, but they would not assess body temperature that way. In addition, if they used a method to cool athletes, most HS ATs relied on whirlpools that were in the athletic training room but not necessarily close to the fields, or on “kiddie” pools or tarps. Another issue that was discussed centered on ice supply. Participants thought maintaining cold drinking water during competition was a priority and a reason they could not maintain a CWI tub. Bob said, “I just wouldn't have the ice to maintain [CWI]. By the second or third day of practice my ice machine would be empty.” Sally agreed: “We are always low on ice, but we need a lot because the water comes out at 80[°F; 26.7°C] or 90°[F; 32.2°C] from the wall, and we need a lot to cool it down, and there is nothing left for submersion afterward, which is tough.”

In addition to small budgets, many ATs expressed concern about appropriate staffing at their clinical settings. Jeff discussed his current situation:

We are very spread out; we have teams all over the place, and I'm the only AT, so you depend on the coaches to recognize and treat it. They're all certified in CPR [cardiopulmonary resuscitation] and first aid, but how much training they get in heat-related illness is a whole new ball game. I don't think they touch too much on that when they do CPR and first-aid training, so I'm not sure how some of the coaches would react if we had a problem; it could end up being a problem.

Sue agreed that her situation was similar:

Our facilities are so spread out [over town] that we are not able to be at everything. So our baseball and softball field is 10 to 15 miles away from school, so it's really hard, and the coaches are not well educated enough. I feel like when we're there, yes, we're prepared, but whenever we're not, they're not.

The recurring opinion from HS ATs was centered on concern with adequate medical coverage, and although their coaches are certified in CPR, they discussed not being able to provide appropriate medical coverage. Implementation of recommended practices is hindered by deficient medical coverage, budgetary constraints, and even a lack of ice for management of potential EHS in the HS setting.

Overall, HS and collegiate ATs mentioned 5 themes causing a gap between EBP and clinical practice regarding recognition and treatment of EHS. Both HS and collegiate ATs showed (1) lack of knowledge, (2) substandard comfort level, and (3) lack of initiative affecting the way they recognize and treat EHS. In addition, (1) liability concerns and (2) lack of resources were 2 additional themes expressed by HS ATs.

Lack of Knowledge

Although it is not an entirely new concept, only recently has EBP been popularized in the athletic training profession. The foundations of EBP are centered on patients and focused on the best available methods, as documented by current research concentrated on diagnostic tests, treatment techniques, and preventive programs.28 The push for a more evidence-based model within athletic training is not meant to replace clinical judgment but rather is intended to improve clinical practice through scientific rigor to provide optimal care and assess the effectiveness of daily clinical practices.2829 The challenges to implementing EBP are entrenched in the amount of time associated with reviewing clinically relevant literature, the lack of formal training in the process or concept of EBP, and the rapid growth of the medical literature. Furthermore, researchers have documented that health care professionals rely heavily on previous formal training when determining clinical management.30 This is similar to the perspective of the participants in our study, in which the education they received is not consistent with the current stance outlined by Binkley et al.8 Many of our participants' perceptions and knowledge of EHS do not reflect the current scope of practice as scientifically documented. Furthermore, although many of the participants reported reading the NATA position statement on EHI,8 they had not received formal training or practice with the skills of T_re and CWI as they had with skills such as CPR or spine boarding. This lack of both knowledge and structured hands-on training has created a domino effect: Clinicians leave school without the skills necessary to manage a case of EHS. These consistent insufficiencies directly influence ATs' preferences to use alternative methods regardless of scientific evaluation or validity. Although clinical practices are constantly changing and being improved based on EBP, the clinician is responsible for staying informed about new research by reading NATA position statements and the professional literature and participating in continuing education opportunities. As medical professionals, ATs should strive to provide the best care to all their athletes on a daily basis. Staying informed about current EBP is crucial in achieving this goal. As shown in Figure 2, if the cycle is not broken, nothing will change clinically, and this gap will not be eliminated.

Comfort Level

Our participants acknowledged not receiving formal training in the skill sets of T_re and CWI during their educational training, which has been identified as a potential barrier to EBP.30 Athletic training students (ATSs) learn best when instructors provide opportunities for structured, hands-on practice.3132 We also know that ATSs seek authentic experiences to reinforce classroom learning and to gain confidence in their skills.32 Therefore, we can infer that when an ATS does not receive formal training, he or she is less apt to develop clinical competence and confidence in those skills upon entering the workforce and will rely on formal training regardless of best practices. The results of the Likert-scale questions were interesting because the average comfort levels for addressing EHS were 6 for collegiate and 8 for HS ATs. The average familiarity and comfort with the NATA position statement on EHI8 were 4 and 5, respectively, for collegiate and 4 and 4, respectively, for HS ATs. This suggests that although ATs seem comfortable when addressing EHS, they might not be diagnosing and treating it correctly based on the NATA position statement.8 Another possibility may be the participants' perceptions of heat-related conditions; they are very comfortable treating the more common heat-related conditions, such as heat cramps and exhaustion, but are not comfortable treating EHS. The high scores on the Likert scale also might indicate the participants' lack of appreciation for the seriousness of the condition and the likelihood of its incidence. The concept of lack of comfort with the skills of T_re and CWI has been cited as a major barrier to implementation of these practices.1 We recognize that taking a rectal temperature or using CWI can be uncomfortable for both the patient and the medical provider; however, this should not trump implementation of appropriate medical care or diagnosis, especially considering that dying of EHS is preventable. As medical professionals, ATs should be able to act as professionals and take a rectal temperature without reservation. The NATA position statement on EHI8 clearly states that T_re is the recommended method of obtaining a body temperature and that CWI is the most efficient way to cool a patient with EHS.8 Therefore, these methods should be taught and practiced in the classroom and used in the clinical setting without discomfort or fear of liability. More continuing education opportunities that incorporate hands-on learning and practice of these skills on human or anatomic models should be available and mandatory. This would increase clinicians' comfort levels with important skills that are not used daily. It also would make the use of the recommended methods, such as T_re and CWI, for the assessment and treatment of EHS more common because we know that clinicians rely on skill and expertise when determining clinical practices.303334 Many instructional methods have been designed to address high-risk educational competencies but rarely are used for clinical skills.3334 However, effectiveness and the development of confidence and competence depend on realism and practical application.3334 Many procedures that ATs are required to do, such as a physical examination for a possible adductor strain, can be uncomfortable, but that is not a good reason to omit them and would not hold up in court.

Lack of Initiative

Lack of initiative is the last theme demonstrated by both collegiate and HS ATs and was not found previously regarding barriers to implementation of best practices pertaining to EHS.1 In the collegiate setting, policies seemed not to have changed because the head AT did not agree with proposed changes or was apprehensive about changing them. Another plausible explanation is the apprehension of younger AT professionals, including full-time staff members, graduate assistants, and ATSs, in voicing their own practice beliefs, voicing their knowledge on the topic, or challenging the authority of their superiors. Furthermore, they might have faced lack of support from those above the head AT, including athletic administrators or team physicians. However, in the HS setting, lack of initiative stemmed from a lack of time or resources to support the necessary changes in policies and emergency action plans. Regardless of clinical setting, this finding is alarming because these practicing ATs are allowing fear and apprehension to thwart the implementation of best practices. These lifesaving procedures are vitally important for an AT providing care for patients with EHS.812 Ultimately, this identified lack of initiative is a violation of the NATA Code of Ethics,19 which insists that ATs adhere to rules, regulations, and practices as established by the governing bodies. Furthermore, as noted with regard to comfort level, this defense will not hold up in court, especially in an HS setting in which the AT plays a major role in developing the school's emergency action plan and treatment regulations. However, one point of contention is the role of team physicians and their practice beliefs regarding EHS. This information has not been identified, and future investigators should examine the effect team physicians have on the ATs' implementation of T_re and CWI and on schools' development of EHS policy. Concluding that they hold a strong influence over ATs' decisions and implementation of best practices is plausible because an AT serves under their supervision; knowledgeable team physicians might be key in moving toward EBP. Regardless, ATs, particularly in the HS setting, might include language in their standing orders to describe the steps for evaluating life-threatening conditions, which should include T_re and CWI for EHS.

Liability Concerns

Liability concerns was one of 2 themes more prevalent with HS than collegiate focus group participants. This finding was expected because most athletes at the HS level are minors, which imposes myriad issues. These include obtaining parental consent, gaining understanding of the techniques being used. and overcoming the negative connotations associated with those intervention guidelines, particularly with T_re. This trepidation is understandable, but ATs are medical professionals and need to remember their codes, which will protect them as they implement these valid and reliable measures as long as they act professionally and have adequate suspicion of EHS before implementation.19 Similar conclusions can be drawn for the use of an automated external defibrillator in the treatment of a potential cardiac condition and for implementation of T_re and can help dictate appropriate treatment, which can save a life. Application of an automated external defibrillator in some instances might lead to exposure of the bare chest; however, regardless of pad placement and skin exposure, the treatment must be implemented. This mindset should transfer to application of T_re and CWI despite its potential awkwardness.

Many participants in focus group interviews did not use proper medical terminology when discussing issues regarding T_re and CWI. Words such as kids and comments such as “sticking a thermometer up somebody's butt” were used throughout the interviews, demonstrating some ATs' disregard for the seriousness of the condition and their lack of knowledge of best practices. This improper use of terminology might reflect their lack of training and true understanding of the effectiveness, ease of use, and practicality of T_re. When discussing the proper steps for diagnosing this potentially fatal condition, ATs need to use the most appropriate language, including “assessing body temperature of the patient via T_re.” Transitioning to this language not only solidifies the AT's place in the health care field but also might alleviate some misconceptions about T_re use in the clinical setting. Furthermore, without proper use of terminology, particularly related to T_re and CWI, the AT will be unable to educate and convince parents, coaches, and athletic administrators about the necessity of the measures. Regardless of clinical setting, the AT must demonstrate confidence and professionalism when addressing a potential case of EHS because this approach can ease much of the tension and misgivings that might accompany T_re and CWI. Furthermore, the AT must begin to embrace the notion that T_re and CWI are best practices and begin to implement these practices with confidence. The NATA endorses these practices, as outlined in the position statement on EHI, which provides the necessary written document to support their use.8 However, one recommendation might be that a coach or the athletic director should be present when the AT uses one of these devices to ensure appropriate care and to protect both parties.

Lack of Resources

Lack of resources or athletic coverage is a struggle that most HS ATs face.1 However, purchasing T_re devices and CWI tubs should not exceed an athletic training budget. In an emergency, a rectal temperature can be obtained via most standard thermometers, which every AT should have. A T_re device can be purchased for less than $200, which fits into most athletic training budgets. However, if this is not possible, rectal temperature can (and should) still be measured with a standard thermometer. Staff should read the thermometer's manual carefully because it will indicate whether the thermometer can be used rectally and whether the device measures temperatures equal to or greater than 104°F (40.03°C). Supplies associated with CWI include consumable items such as ice and water and, for a small cost (approximately $150), a polyethylene tub. Moreover, some of the participants indicated a concern with running out of ice, which was necessary to help maintain the hydration of their athletes. A simple solution can include purchasing additional bags of ice daily at a local convenience store or having regular ice delivery. This cost should fit within an AT's budget, considering the documented efficiency of cooling a patient with a dangerously elevated core temperature.1718 Researchers have shown that schools with AT services and sports medicine supply budgets provide higher levels of medical care than schools without them.35 Again, our results and those of researchers studying barriers to the use of recommended practices for the recognition and treatment of EHS have demonstrated a clear picture; a lack of previous training and complete understanding of EHS has led ATs to avoid purchasing or even requesting the necessary equipment for the accurate diagnosis of potential EHS and the appropriate tools to adequately treat affected athletes.

Limitations

Although the ATs who participated in our study represented a random sample from the HS and collegiate settings, the findings might not represent fully the educational training, practice beliefs, and experiences of all ATs. We recognize that the sample was small compared with the number of ATs employed in both clinical settings; however, we wanted to gain further insights into barriers to the use of EBP and the recognition and treatment of EHS as identified in the literature. In the future, perhaps a more homogeneous sample would help strengthen the findings and expose more setting-specific barriers. We also recognize that using focus groups as the data collection method has its own limitations, such that participants might have felt pressured to provide similar responses. Future investigators might choose to use individual interviews to confirm our findings.

Future Research

In the future, researchers should include surveys and interviews of different health care professionals who are involved in the recognition and treatment of EHS. This population would include coaches, parents, team physicians, emergency medical technicians, paramedics, and emergency department physicians. With information from all these realms, a consistent reason for this disconnect might emerge. We assumed that rectal temperature assessment is frowned on by people who are unaware of the reason for its use. However, no investigators have examined the response of parents, administrators, coaches, and others who are told about the use of T_re and how it can lead to the successful outcome for a patient with EHS. Formal and continuing education experiences also might help identify a connection between the type of education received and clinical practice. This should begin with hands-on sessions at national meetings, such as the NATA, so appropriate methods can be taught, questions can be answered, and skills can be practiced.