Football Helmet Face Mask Removal

Football Helmet Face Mask Removal
Douglas M. Kieiner, PhD, ATC/R, CSCS
Sports Medicine-Athletic Training Program, University of North Florida
v
j/i-ach
l year numerous head
and neck injuries occur to football
players of all skill levels. These injuries are among the most feared
because they can cause paralysis
or death. Proper on-the-field
management of these injuries is
needed to avoid further injury.
Medical personnel should take
extreme caution when evaluating
and treating an unconscious football player, since the extent of the
injury is unknown.
Any unconscious athlete should
be suspected of having an accompanying spinal injury until it is
proven otherwise. If the athlete is
not breathing, or if there is a possibility of respiratory arrest, it is irnperative that the medical personnel
work quickly and effectively to remove the face mask in order to admi*
ister the proper emergency care.
Helmet Removal
Concerning how to treat a football
player with a suspected spinal injury, both the National Athletic
Trainers' Association and the
American College of Sports Medicine have recently developed statements advising against removal of
football helmets. Athletic therapists, or other first-responders,
should remove only the face mask
in order to gain access to the airway. Preventing the head and neck
movement that would occur during helmet removal is very important because any unnecessary
movement may cause further damage to the cervical spine.
It has been noted that the protocol for football helmet removal
often differs between athletic
therapists and emergency medical
technicians (EMTs).EMTs are frequently confronted with motorcycle accidents involving loosely
fitting helmets and are instructed
to remove them. However, unlike
motorcycle and even other sport
helmets, football helmets fit snugly
and prevent head movement
within the helmet.
Unlike other helmets, the face
mask of a football helmet is attached to the helmet with four
plastic straps that allow for face
mask removal. This design enables
medical personnel to gain access
to the airway and vital areas of the
face, examine the athlete, and administer emergency care without
having to remove the helmet. Furthermore, since football players
wear large shoulder pads, removing the helmet without simultaneously removing the shoulder
pads would interfere with attempts
to maintain in-line neutral stabilization of the spine.
To avoid potential conflicts
between athletic therapists and
EMTs as a result of their different
protocols, athletic therapists
should take the initiative before a
problem arises by scheduling a
meeting with the local providers
of emergency medical services. It
is suggested that team physicians,
athletic therapists, coaches, and
concerned parents meet with
emergency care providers such as
EMTs to develop a protocol for the
safe transportation of athletes who
have suffered catastrophic injuries.
Only a qualified physician
should remove the helmet of a
football player who is thought to
have a spinal injury-and only after x-rays have been obtained at
the hospital. In the past, attention
has focused on the topic of helmet
removal versus face mask removal.
However, now that helmet removal
is widely disregarded and face
mask removal is the well accepted
protocol, scientific investigations
are beginning to identify which
tools and face mask removal techniques are most efficient.
Face Mask Removal
The face mask is attached to the
football helmet by four plastic
straps (Figure 1). The lower two
63 1996 Human Kinetics
January 1996
Athletic Therapy Today
11
straps may be cut or removed, allowing the face mask to be retracted with the two top straps acting as a hinge. This design enables
the athletic therapist to gain access
to the airway without having to
remove the helmet. The plastic
straps can be removed with special
tools, which should be readily
available during practices as well
as games.
There are several theories on
face mask removal. It has been
suggested that the face mask need
not be removed, and that when
cardiopulmonary resuscitation
(CPR) is indicated, a CPR pocket
mask should be inserted between
the face mask bar and the athlete's
face. Although there is some support for this theory (Ray et al.,
1995), several potential problems
exist:
1. It may be difficult to attempt
this maneuver, particularly
with the detachable one-way
valve found on many CPR
pocket masks. For one thing,
the pocket mask might not fit
under the face mask, particularly if the face mask is damaged, distorted, or has not
been fitted correctly.
2. The EMTs may want to intubate the athlete or they may
have a protocol that does not
allow for transportation under these conditions.
3. This method does not allow
for easy evaluation of other
vital signs, particularly if
the athlete is wearing a face
shield.
Another theory is that the
present a problem because time
becomes more critical once the
athlete is in respiratory arrest.
Therefore it is suggested that athletic therapists not wait until the
athlete stops breathing to begin
the necessary task of face mask
removal.
Still another theory is that
the face mask should always be
removed as quickly as possible
any time an athlete is suspected
of having a head or neck injury,
even if the athlete is still conscious. Since the face mask might
need to be removed for evaluation of vital signs, or for transportation, and possibly for CPR, the
thinking is that it may as well be
removed sooner rather than later.
This protocol may also avoid a
potential problem concerning
emergency medical personnel.
That is, once EMTs arrive on the
scene and see that the face mask
has already been removed, giving
them unobstructed access to the
face, they may agree to transport
the athlete without removing the
helmet.
Tools for k c e Mask
Removal
Several tools that can be used to
remove the straps securing the
face mask to the helmet are mentioned in the literature (Rehberg,
1995).But little research has been
done on the forces and movements that occur to the neck when
removing the face mask in an experimental setting, and on the
valuable time it takes to remove
the face mask.
The Trainers AngelTMis currently the most widely used tool
for
mask"__.
removal, but
- "it has
----face
recently been scrutinized in
scientific investigations. Of 50
certified athletic trainers surveyed
by Kleiner and Knox (1995), 54%
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Athletic Therapy Today
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reported that the Trainers AngelTM
is the tool they carry for face
mask removal. Other tools mentioned in that survey were, a scalpel or knife, DuraShears or "paramedic scissors," and screwdrivers,
each used by 12% of the athletic
trainers. The remaining 10% reported "other" or "none."
The same athletic trainers
were also observed for the technique they use with the Trainers
AngelTM.Despite the fact it was
their tool of choice, only 12% actually used it according to the technique recommended by the manufacturer. Furthermore, 60% had
difficulty cutting through the
straps or had to use both hands
with the Trainers AngelTM,and
most of them were unable to cut
the strap thoroughly on their first
attempt. It was also reported that
68% of the athletic trainers had
never practiced using the Trainers
AngelTM.
The researchers concluded
that while the Trainers AngelTM
may be a satisfactory tool, it should
have better instructions for use.
They further recommended that
athletic trainers practice the skill
of face mask removal.
Since head and neck movement should be minimized during
face mask removal, and the task
should be accomplished as quickly
as possible, the tools for face mask
removal should be efficient in
both regards. Several tools have recently been evaluated in a series
of experiments conducted by this
author. The first of these (Knox
et al., 1995) evaluated a Phillips
screwdriver, the Trainers AngelTM,
and~~a,modified-anviLpr~ne~
Ax,. .,,
fourth tool, a utility knife, was removed from the experiment after
the first two subjects injured themselves while trying to cut the face
_
January 1996
mask straps. Data were also removed when another subject damaged a screw beyond repair while
using the Phillips screwdriver,
making it impossible to remove
the face mask.
The remaining data revealed
that it took longer to remove the
two lower face mask straps when
using the screwdriver than when
cutting off the straps with the
Trainers AngelTMo r the anvil
pruner. But it was also found that
the Trainers AngelTMproduced
more head movement than the
other two tools. The anvil pruner
was the tool the subjects preferred
most.
Finally, data were analyzed
with regard to the subjects' qualifications. It was found that student
athletic trainers could remove the
face mask as quickly as could the
certified athletic trainers and
EMTs, and with significantly less
head and neck movement than
was produced by the certified athletic trainers.
In a n unpublished study,
certified athletic trainers and
EMTs were asked to remove the
two lower face mask straps with
DuraShears scissors. The preliminary results from this experiment
revealed that it took most subjects
more than 8 minutes to remove
the straps, and one subject took a
full 35 minutes! Worse, the data
from another had to be withdrawn
because he quit the experiment
when he failed to remove the first
of the two lower face mask straps
after trying for over an hour.
Swing-Away
vs. Removal
Currently it is accepted practice to
remove the two lower straps that
secure the face mask to the helJanuary 1996
It should be stressed here that
face mask removal is a learned skill
that needs to be practiced. Furthermore, consideration should
be given to including the skill of
face mask removal as a competency for entry-level certified athletic trainers. Further research and
the development of alternative
methods for face mask removal are
warranted and are forthcoming.
met, and then to retract or "swingaway" the face mask using the top
two straps as a hinge (Figure 2).
However, recent data from our
laboratory indicate that most of
the head and neck movement that
occurs while gaining access to the
athlete's airway occurs while the
face mask is being retracted, not
while the straps a r e being
cut (Trainers AngelTMor anvil
pruner) or removed (screwdriver).
This suggests that if an adequate
tool is available, and if the athletic
therapists are practiced in the skill
of face mask removal, all four
straps should be cut and the face
mask should be removed rather
than retracted.
Kleiner, D.M., & Knox, KE. (1995). An evaluation of the techniques used by athletic
trainers when removing a face mask with
Journal of Athletic
the Trainers AngelTM.
Training, 30 (2), S7.
Knox, K.E., Kleiner, D.M., McCaw, S.T., &
Ryan, M.A. (1995). The effects of qualifications on the efficiency of football
helmet facemask removal with various
tools. Journal of Athletic Training, 30(2),
S7.
Ray, R.R., Luchies, C., Famell, R., & Bazuin,
D. (1995). Airway preparation techniques for the cervical-spine-injured
football player. Journal ofAthletic Training, 30(2), S7.
Rehberg, R.S. (1995,Jan.). Rating face mask
removal tools. NATA News, pp. 26-27.
Acknowledgment - Thanks to Kris E. Knox,
MS, ATC, EMT-A, for all his assistance with the
research on this topic.
Conclusions
While neck and head injuries will
continue to be life threatening,
the proper management of these
injuries may prevent further injury
from occurring. Proper management includes the following:
1. Leave the helmet in place
whenever possible.
2. Remove only the face mask,
not the helmet.
3. Develop a plan for managing
head and neck injuries using
expert sports medicine personnel such as certified athletic trainers.
Athletic Therapy Today
Douglas M. Kleiner is an assistant professor and director of the Sports ~ e d i c i n e Athletic Training Program at the University of North Florida. He also directs the
sports injury research lab at UNF. He
holds a doctorate from Auburn and has
presented several papers on the emergency management of football injuries.
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