Helmet Removal in Athletics

A local EMS agency is providing standby services at a local high school football game, just as they have for many similar events. It’s been a pretty quiet night, only requiring a Band-Aid for a scraped knee on a kid who slipped in the bleachers. Suddenly, play stops on the field, and an official summons the coach to aid a player who is down and not moving. After a few minutes, they motion for the EMS crew to come onto the field. Following their jog to the opposite end of the field, the coach tells them the athlete said his neck hurts and he can’t feel his fingers. Now what?

This is not an MVA, and the player is not wearing a motorcycle helmet. Should they leave the helmet on or take it off? They can’t put a c-collar on with those pads in the way! How do they deal with all the football equipment? It has to come off, right? The answers to these questions are not always clear-cut. Several factors must be considered.

Basic C-Spine Anatomy

As with any injury, knowing basic anatomy is helpful when providing treatment. To quickly review: The spine consists of 33 vertebrae, each of which has a hollow opening (see Figure 1) that together creates a canal running from the top to the bottom of the spine, which houses the spinal cord.

Nerves that branch off the spinal cord at various levels send information back to the brain, which then uses that information to control things like sensation, movement and other necessary functions within the body. When injury occurs to the spine, these nerves can become injured or damaged, resulting in paralysis or paresthesia.

The dermatome is the area of skin innervated by a nerve from the spinal cord that can indicate at what level the spinal cord is injured by the area of the body that is displaying signs of paralysis or paresthesia. Although knowing this probably won’t change patient treatment, it is another “tool” to use when performing an assessment.

The majority of spine injuries in athletics occur high in the spinal column, usually at the C2–C5 level. If damaged, the nerves in the upper C-spine area can affect the patient’s breathing. If an injury occurs high in the C2–C4 area, even temporarily, an injured athlete may stop breathing. This is obviously a problem that EMS needs to be aware of and prepared to handle quickly.

Injury Assessment and Treatment

Drawing on this basic knowledge of anatomy, begin your systematic assessment with the ABCs. Make sure the athlete has a patent airway and is breathing at an adequate rate. If the athlete can talk to you, even if he doesn’t know what zip code he’s in, you have assessed his airway. A small but key item to remember is that breathing and speaking, especially when lying on your back, is much easier without a mouthpiece in the way. If the athlete is wearing a mouth guard, take it out!

The injured athlete in the opening scenario said he had neck pain and his arms and hands were tingling. As with any potential neck injury, C-spine stabilization is an important factor to prevent further injury and should be performed right away. This should actually be done prior to, or in conjunction with, assessing the ABCs. Obviously, preventing or minimizing further movement is a key factor in treating this patient.

Helmet Removal vs. Nonremoval

So, what happens now? Take the helmet off, or leave it on?

To answer that question, there are some key factors to consider. First, does the helmet fit properly? If there are few or no gaps between the forehead pad, cheek or jaw pads and the athlete’s head, it fits properly. With a properly fit helmet, this athlete basically has a cervical immobilization device (CID) on his head.

Another consideration for helmet removal is airway access and how quickly access is needed. If the athlete is conscious and talking, airway access is not an immediate concern. That doesn’t mean that won’t change, but we’ll address that aspect later in this article.

If the helmet fits properly and immediate airway access is not a concern, it is not necessary to remove the helmet. The only problem is the facemask, which is easily solved without removing the helmet.

With these factors in mind, it is rarely necessary to remove the helmet in order to treat, package and transport the athlete. This is contrary to what many EMS personnel believe or practice; however, it is the latest recommendation for treating C-spine injuries in athletes. This was recommended by a joint task force of EMS, sports medicine, physicians and other healthcare professionals through the National Athletic Trainers’ Association in a recently released report, Prehospital Care of the Spine-Injured Athlete, which can be found online at www.nata.org/spineinjuredathlete/main.htm.

Facemask Removal

Removing the facemask not only allows better access to the airway, if needed, it also makes patient packaging easier and often minimizes the athlete’s anxiety level by improving his ability to see what is going on. If the athletic trainer is available, have him assist with removing the facemask. There is a very high probability that he has performed this task on more than one occasion.

So, what’s the best way to get a facemask off? Several factors may determine the best method for you, one of which may be personal preference. For the most part, there are a few specific techniques that yield the best results.

Most facemasks are held in place by 4–6 plastic clips. Removing the screws that hold the clip hardware in place allows the facemask to easily be removed from the helmet.

If a helmet is not well maintained, however, the facemask hardware may have become rusted over time, which can cause the “T” nut on the inside of the helmet to spin and prevent removal of the hardware. In this instance, it may be necessary to cut the clips. These clips are made of a very dense plastic, making them difficult to cut. It goes without saying that you need to prevent any movement of the athlete’s head when performing this task.

Although there is not a “best” tool for cutting the clips, there are some tools that would be a definite do not use, such as the shears you may have hanging on your belt. While they may be great for cutting seat belts and clothing, they don’t work in this situation.

There are tools specifically designed for performing this task, including the Trainers Angel and the FM Extractor (Figures 2 and 3), among others. A basic anvil pruner (see Figure 4), available from the local hardware store, also works very well for this task. Most anvil pruners have a Teflon blade that is very durable and very sharp. This type of blade makes cutting the hard plastic clips relatively easy; however, it still takes a significant amount of grip strength.

Whichever tool is selected, all of the clips must be cut completely to release the mask. The clips have two layers: a top and a bottom layer that wraps around the actual facemask. Figure 5 shows the clips being removed using an anvil pruner.

We have already discussed some of the reasons for early helmet removal, such as helping to lower the injured athlete’s anxiety level and making patient packaging easier, but another important reason is airway access. While acquiring easier access to the athlete’s airway may not be an issue initially, that can change rapidly, as with any patient we treat. One condition that could change this is increased swelling of the injured spinal cord within the spinal canal. If swelling occurs, it can place pressure on the spinal cord, making it difficult for the body to maintain spontaneous respiration. If the facemask is removed early in the process, airway access is readily available if an airway emergency occurs.

Patient Packaging

With the facemask removed, you can now complete full patient packaging and prepare for transport. There are varied opinions on the best method for placing the athlete on a backboard. The method used can depend on the size of the athlete. While it may be possible to move a smaller athlete to the backboard using a six-person lift, as recommended by the task force, this can be difficult with a larger athlete. With larger patients, you may have a better result with the log roll method, or using a scoop stretcher, which eliminates the need to roll the patient at all. Whatever method is used, teamwork and communication are key in maintaining alignment of the athlete, which is your main goal.

A scoop stretcher works well because both the slant to the head portion of the board and the gap serve to cradle the helmet. Securing the head properly is like trying to secure a bowling ball on a tabletop, which is another reason that the CIDs most of us carry are not recommended. Most block CIDs, as shown in Figure 6, do not provide adequate height on the sides of the helmet to firmly secure the head.

Once the athlete is moved to the backboard or scoop stretcher, and before he is secured to the backboard, some other steps are recommended. One is to remove the jersey from the patient by cutting it up the middle. If you want to make some PR points for your EMS service, cut the jersey along both sides from the bottom up to the axilla area, under the sleeve and across the top of the shoulder pads on both sides. This creates two pieces of jersey that can be sewn back together. This will salvage a $100 jersey and make you very popular with the athletic director!

Once the jersey is removed and the shoulder pads are exposed, cut the string that holds the shoulder pads together in the center and the elastic straps that run under the arms. These items are inexpensive and should be cut. Trying to untie or release them from the hardware could necessitate moving the athlete, which you don’t want. If the weather is inclement, remove the jersey after the athlete is inside the ambulance, before transport. Simply remove the straps securing the athlete to the backboard, remove the jersey and shoulder straps, and replace the quick-clip straps.

By removing the jersey and releasing the center and shoulder straps, you gain full access to the athlete’s upper torso to perform any type of assessment or treatment necessary, including CPR or defibrillation.

Removing Equipment

In the rare instance that the helmet needs to be removed, it should be understood that the helmet and shoulder pads are considered one unit. If you remove the helmet, you must also remove the shoulder pads. Removing the helmet but not the shoulder pads places the head in hyperextension, which jeopardizes C-spine alignment, as shown in Figure 7. If necessary, place a blanket behind the head to maintain C-spine alignment (see Figure 8).

In most cases, the helmet and shoulder pads will not need to be removed. Simply remove the facemask, package the athlete and transport.

Summary

C-spine management in athletics by EMS is an ongoing topic of discussion. While there is obviously more than one method to achieve the end goal, a few techniques are no longer recommended. Probably the biggest change, as discussed here, is that the helmet really does not need to be removed for transport.

However, as recommended by the Interagency Task Force, the facemask should be removed if the athlete needs to be transported. In this case, regardless of the tool used to do it, the facemask must be removed completely and quickly, without causing any additional undue movement of the patient’s head. Ensure that all of the retaining clips on the facemask are cut completely to allow easier access to the injured athlete.

We need to be open to new thoughts about how to handle specific patients, provided those methods are well researched and thought out, as is the case with the latest techniques discussed here. I highly recommend that every EMS service or provider obtain a reference copy of the task force findings from the National Athletic Trainers Association website at www.nata.org, or call 800/TRY-NATA.

Resources

Human Anatomy and Physiology; 6th Edition. Hole J, Jr., Brown WC, Publishers, 1993.

Taber’s Cyclopedic Medical Dictionary, 17th Edition. Philadelphia, PA: F.A. Davis Co., pp. 1427, 1989.