UTEP Concussion Policy and C3 Logix Testing

The University of Texas at El Paso Department of Athletics will follow the guidelines below regarding concussion diagnosis and management.

As of August 1st, 2016, baseline testing will include C3 Logix integrated testing with concussion history, a baseline symptom score, digital SAC test, BESS testing on two surfaces, and a neurocognitive testing battery. These baselines will be completed prior to the student-athlete’s first competition, and all sports will complete new baseline testing by September 15th of that year

In subsequent semesters, the concussion baseline will serve as a part of the pre- participation exam.

The following sports at UTEP will complete the C3 Logix pre-participation assessment:

 Football  Men’s  Women’s Basketball  Volleyball  Women’s Soccer  Softball  Track and Field (Pole-vaulters only)  Cheerleading

NCAA Recommendations and UTEP Protocol:

The components of the UTEP Sports Medicine Concussion Protocol are the following, and the entire document is available upon request or on our website:

1. Education: o UTEP athletic trainers present concussion NCAA/CDC concussion facts to student athletes prior to every competition season and get a signed acknowledgement that those student athletes have received and understand the information given to them. o These fact sheets are presented during team meetings prior to the season. Coaches are present at these meetings and also receive concussion fact sheets. o Team physicians review the UTEP Concussion Policy annually and are given copies of the policy. o All parties, including the athletic training staff and office of the athletic director sign an acknowledgment that they have received and understand the material

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2. Pre-participation assessment: A one-time, pre-participation baseline concussion assessment for all varsity student-athletes should include, but not necessarily be limited to: o A brain injury/concussion history; o Symptom evaluation; o Cognitive assessment; and o Balance evaluation.

The team physician will determine pre-participation clearance and/or the need for additional consultation or testing. Athletes that suffer a concussion will be re-baselined at least six-months after, or before their next competition season.

Recognition and Diagnosis of Concussion: All student-athletes who are experiencing signs, symptoms or behaviors consistent with a sport-related concussion, at rest or with exertion, must be removed from practice or competition and referred to an athletic trainer or team physician with experience in concussion management. A student-athlete’s health care provider experienced in the diagnosis and management of concussion should conduct and document serial clinical evaluation inclusive of symptom inventory and evaluation of cognition and balance. A student- athlete diagnosed with sport-related concussion should not be allowed to return to play in the current game or practice and should be withheld from athletic activity for the remainder of the day. Disposition decisions for more serious injuries such as cervical spine trauma, skull fracture or intracranial bleed, should be made at the time of presentation.

Initial Suspected Concussion Evaluation: The foundation of sport-related concussion management is initial physical and relative cognitive rest as part of an individualized treatment plan. Initial management of sport-related concussion is based on individual serial clinical assessments, taking a concussion history, modifying factors, and taking specific needs of the student-athlete into consideration. Such management includes, but is not limited to:

 Clinical evaluation is at the time of injury. When the rapid assessment of concussion is necessary (e.g., during competition), symptom assessment, physical and neurological exam, and balance exam should be performed. UTEP Sports Medicine utilizes the SCAT-5 and other acceptable sideline evaluation tools, which include the Standardized Assessment of Concussion (SAC).  Evaluation will include at the minimum a symptom assessment, physical and neurological assessment, cognitive assessment, and balance exam.  Assessment for head and cervical spine injury at time of injury and implementation of the emergency action plan, as warranted.  Transportation to the nearest hospital if any of following signs and symptoms are present: Glasgow Coma score less than 13; prolonged period of loss of consciousness (longer than 1 minute); focal neurological deficit; 2

repetitive emesis; persistently diminished or worsening mental status or other neurological signs or symptoms; and potential spine injury.  Serial evaluation and monitoring for deterioration following injury. Upon discharge from medical care, both oral and written instructions for home care should be given to the student-athlete and to a responsible adult (e.g., parent or roommate) who should continue to monitor and supervise the student-athlete during the acute phase of sport-related concussion.

Concussion Diagnosis and Management

Diagnosis and management of sport-related concussion is a clinical diagnosis based on the judgment of the athletic trainer and other UTEP health care providers. The diagnosis and management of sport-related concussion is challenging for many reasons:

 The physical and cognitive examinations are often normal, and additional tests such as brain computerized tomography (CT), brain MRI, electroencephalogram and blood tests are also commonly normal. Although comprehensive neuropsychological tests may be a useful adjunctive tool supporting the diagnosis of sport-related concussion, there remains controversy regarding interpretation and utility as a clinical tool.  The clinical effects of sport-related concussion are often subtle and difficult to detect with existing sport-related concussion assessment tools.  The symptoms of sport-related concussion are not specific to concussion and it is challenging to evaluate a student-athlete who presents non-specific symptoms that may be related to other conditions.  Sport-related concussion may manifest with immediate or delayed-onset symptoms. Symptom manifestation can vary between individuals and in the same individual who has suffered a repeat concussion.  Modifying factors and co-morbidities -- such as attention deficit hyperactivity disorder, migraine and other headache disorders, learning disabilities and mood disorders -- should be considered in making the diagnosis, in providing a management plan, and in making both return-to-play and return-to-learn recommendations.  “Signal detection” on clinical measures (e.g., cognitive and balance testing) often quickly diminishes in the acute setting of early recovery. Although cognitive function and balance assessed within 24 hours with various sideline tests (Standardized Assessment of Concussion [SAC] and Balance Error Scoring System, respectively) have been shown to be useful in diagnosing concussion, these tests often normalize within a few days and cannot be used to make a definitive diagnosis.  Student-athletes may underreport symptoms and inflate their level of recovery in hopes of being rapidly cleared for return to competition.

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 Clinical assessment of sport-related concussion is a surrogate index of recovery and not a direct measure of brain structure and functional integrity after concussion.  Further Medical evaluation may be necessary in the event of a prolonged recovery to rule out or consider any differential diagnosis. *Additional diagnoses include, but are not limited to:  Post-concussion syndrome.  Sleep dysfunction.  Migraine or other headache disorders.  Mood disorders such as anxiety and depression.  Ocular or vestibular dysfunction.

UTEP athletic trainers who are trained in the diagnosis, treatment and initial management of acute concussion will be “present” at all NCAA varsity competitions in the following contact/collision sports: basketball; football; pole vault; soccer, softball, and volleyball. Furthermore, UTEP athletic trainers who are trained in the diagnosis, treatment and initial management of acute concussion will be “available” at all NCAA varsity practices in the following sports: tennis, golf, rifle, cross country and track and field.

NCAA Guidelines and UTEP Treatment Protocol:

A. When any student-athlete shows signs, symptoms, or behaviors consistent with a concussion, they will be removed from participation and evaluated by a certified athletic trainer, licensed athletic trainer, physician assistant, or team physician with experience in evaluation and management of concussion. The student-athlete will then have a follow up visit with a team physician at the next Larry K. Durham clinic time, or at that physician’s clinic. B. Student-athletes suspected of having a concussion will be evaluated with the following: a. Symptom assessment b. Physical and neurological exam c. Cognitive assessment d. Balance e. Assessment for cervical spine trauma, skull fracture, and intracranial bleed C. A student-athlete who has been diagnosed with a concussion shall be held out of participation for a minimum of 24-hours a. Diagnosis is to be made based on the individual provider’s expertise D. Student-athletes will be provided with written instructions upon discharge. Written instructions should preferably be given to a roommate or guardian. E. The student-athlete will undergo a “Graded Symptom Checklist” every 24- hours following the diagnosis of a concussion F. Once asymptomatic, the student-athlete will take the full test battery of the C3 Logix system.

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G. Once asymptomatic and post-exertion assessments are within normal limits, the return to play protocol may begin. H. Final authority for Return‐to‐Play shall reside with the team physician or the physician’s designee. I. UTEP Sports Medicine personnel will document the incident in C3 Logix and the evaluation, continued management, and clearance in Sportsware J. Although sports currently have rules in place; athletics staff, student‐athletes and officials should continue to emphasize that purposeful or flagrant head or neck contact in any sport should not be permitted and current rules of play should be strictly enforced.

Post-Concussion Management Continued:

A. Consult the specific sport’s EAP in the event of the following red flags: a. Glasgow coma scale <13 b. Prolonged LOC c. Focal neurological deficit suggesting intracranial trauma d. Repeated vomiting e. Diminishing mental status f. Worsening neurological signs and symptoms g. Spinal injury

Procedure:

1. Following the diagnosis of a concussion, the student-athlete will complete the “Graded Symptom Checklist” every 24-hours until they are asymptomatic.

2. The student-athlete will follow up with Dr. Justin Wright, Dr. Gerry Vasquez, Dr. Daniel Murphy, or one of their designees at the first Larry K. Durham internal medicine clinic following diagnosis.

3. Once asymptomatic, the student-athlete will complete the C3 Logix test battery for baseline comparison.

4. Once they are asymptomatic and their test results are within normal limits or are acceptable compared to their baseline they may start the return to play protocol and Graded Exercise Progression.

5. Tennis, rifle, and track and field will be placed into a category according to their sport demands with consultation from the physician.

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Return to Learn:

The following Return to Learn Protocol (RLP) will be utilized by the sports medicine staff of The University of Texas-El Paso with regard to the management of a student athlete diagnosed with a head injury and their return progression to academics.

-Return to Learn Management Team The athletic trainer designated to cover that specific athlete’s sport will coordinate and navigate the RLP. In complex situations with a perceived prolonged RLP, a multidisciplinary team will be in place to the Student-Athlete’s reappearance in the traditional learning/classroom setting. The Post-Concussion RTL Team will consist of the following:  Athletic Trainer  Team Physician  Heather Smith, Director – Miner athlete academic  Academic Counselor for the athlete’s particular major of study  Additional entities that could join RLP Team:  Office of Disability Services (CASS)  Integrated Treatment Team o Dr. Hector Maldonado, Sharon Ferrel, University Counseling o Dr. Ed Jose Borrego  University Administrators  Dr. Stephen Aley - FAR  Course instructors  Coaches/Support Staff Any action taken must remain in compliance with the Americans with Disabilities Act Amendments Act (ADAAA) and the UTEP Office of Equal Opportunity.

RLP should be managed much like the RTP progression fits the individual and their concussive symptoms Quality RLP is based on cognitive rest immediately following a concussion:  Avoidance of potential cognitive stressors, Examples include: School work; video games; reading; texting Return to Cognitive Activity  After concussion is diagnosed, the Student-Athlete must avoid the classroom, tutoring, mentoring for at least one day. Levels of RLP are based solely on the return of concussion symptoms

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RTL stepwise protocol:

1. It is the responsibility of the student athlete to report any head / concussion injury related symptoms to the Certified Athletic Training staff of the University.

2. A clinical examination and a C3 Logic test will be performed by a member of the Certified Athletic Training staff to evaluate the student athletes head / concussion related injury.

3. If a concussion is suspected, the student athlete will be educated on the importance of both cognitive (mental) and physical rest. A post injury C3 Logic test will be administered. Based upon the results of this test may require removal from physical activity and/or recommended academic accommodations. A student athlete’s removal from physical activity will follow the Return to Play protocol. A student athlete’s step wise return to academics will follow the Return to Learn protocol.

4. Once a diagnosis of a concussion has been determined, the team physician will be notified by a member of the Certified Athletic Training staff. The team physician will then determine if a student athlete should receive academic accommodations. The Athletic trainer will the notify Heather Smith or that athletes academic advisor at the Miner Athlete Academic Center (MAAC). The MAAC will then notify the student athlete’s academic professors that the student athlete is to be excused from cognitive stressors, including class, reading and writing assignments and taking quizzes and/or examinations until they are cleared by the team physician to do so.

5. A stepwise return to academics will be followed, but it must be understood that the student athlete cannot return to participation in their sport until they return fully to academics. A stepwise approach does not include a recommended number of days, but is based upon the individualized time of recovery and it gives the student athlete the right to exercise self‐determination and deny the provision of academic accommodations.

Step 1 > Full Cognitive / Academic Rest … No screens or C3 Logix testing until asymptomatic Step 2 > Light Academic Activity ……………………Limited attendance, light academic work Step 3 > Increased Academic Activity …………….. Increased attendance, academic work load Step 4 > Full Time Attendance ……………Single class exceptions as necessary (ig. PE or labs) Step 5 > Full Academic Program …………Full time attendance for all classes, testing resumes

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*For those student athletes whose symptoms persist for longer than two weeks, the student athlete may need a change of class schedule; special arrangements for extended absences, tests, papers and projects. This will be coordinated through the Miner Athlete Academic Center (UTEP-MAAC).

Specific Graded Exercise Progression

This graded return to play matches the return to play stages from the Zurich Consensus Statement. All UTEP student-athletes will undergo a six-phase return to competition progression as detailed by the following. After every stage, the student-athlete must be evaluated for symptoms and will be supervised by an AT.

Phase 1. No activity until physician clearance. Rest and recovery Phase 2. Bike at a moderate pace to achieve 65-70% maximum heart rate for 20 minutes:  If symptoms arise, immediately discontinue workout  Stage may resume after 24-hours only if the student-athlete is asymptomatic

Phase 3. Sport-specific exercise (see separate section by sport): a. Each student-athlete will start out with a five-minute jog, bike, or elliptical warm up. Outdoor sport distances will be standardized to the football field and indoor sports will be standardized to a

Phase 4. Individual, sport specific, non-contact drills for 15 minutes (see separate section by sport): b. Each student-athlete will complete a five-minute warm up jog OR sport requirement specific warm-up c. SA must return to weights at this time

Phase 5. Full contact practice (for all sports following individual phase 4): d. Limited, controlled return to full contact e. Functional assessment of skills by a coach

Phase 6. Return to competition (for all sports following phase 5) f. No student-athlete may return to full practice or competition without completion of a full-contact practice while remaining asymptomatic

Football Phase 3. 1. O-Line Drills a. 60 yard 5-10-5 shuttle x 3 (75%-85% speed with two minutes rest in between runs) b. Chute drills – fire out and drive x10 (stay low coming out of stance, may use bag) c. Sled drills – Lock out and drive x10 d. Stance and Start Drills

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e. Base step right/Left and sprint 10 yards. f. Pull left/Right and sprint 10 yards. g. Pass set right/Left and sprint 10 yards. 2. D Line a. 60-yard 5-10-5 shuttle x 4 (75%-85% speed with two minutes rest in between runs) b. Sled drills – Lock out and drive x 10 c. Pursuit Drill x 4 (2 minutes rest in between) d. Pass Rush drill with Hoops x 3 each way 3. Quarterbacks a. 60 yard 5-10-5 shuttle x 4 (75%-85% speed with two minutes rest in between runs) b. Roll out Right/Left pass x 5 Each way c. Agility Ladder x 5 (30 seconds rest) d. Cone drills x 5 4. Running Backs a. 60 yard 5-10-5 shuttle x 4 (75%-85% speed with two minutes rest in between runs) b. Agility Ladder x 5 (30 seconds rest) c. Cone drills x 2 (Each) i. Jump cut ii. Bounding iii. Weave iv. Plant and cut d. Stance and Start x 15 yards x 5 ( walk back to start) 5. Wide Receiver and Tight Ends a. 60 yard 5-10-5 shuttle x 4 (75%-85% speed with two minutes rest in between runs) b. Agility Ladder x 5 (30 seconds rest) c. Routes (w/ QB if available) x4 (Each route) i. Curls route ii. Quick outs iii. Slant route iv. Post Route 6. Line backers a. 60 yard 5-10-5 shuttle x 4 (75%-85% speed with two minutes rest in between runs) b. Pass Rush drill with Hoops x 3 each way c. Sled drills – Lock out and drive x 10 d. Agility Ladder x 5 (30 seconds rest) 7. DB and Corners a. 60 yard 5-10-5 shuttle x 4 (75%-85% speed with two minutes rest in between runs) b. Pursuit Drill x 4 (2 minutes rest in between c. Break Drills x2 each (walk back to start) i. Comeback ii. Hitch iii. Post iv. Corner 8. Specialists (kickers/long snappers)

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a. 60 yard 5-10-5 shuttle x 4 (75%-85% speed with two minutes rest in between runs) b. Agility Ladder x 5 (30 seconds rest) c. 10 kicks (for kickers and punters) d. 10 Snaps and sprint 10 yards (long snappers) Phase 4. All Athletes will participate in Non-contact “Red” Jersey practice which consists of position specific drills. Athletes can participate in all team drills, so long as they have no contact with other players as identified with the “Red” jersey.

Basketball Phase 3. 1. Five “ladder” drills o Baseline – line – half court – opposite free throw line – opposite baseline o Runs completed at 75-85% speed with a two-minute rest in between runs 2. 15 squat jumps 3. 15 jumping jacks (or jumps) Phase 4. Each student-athlete will complete a five-minute warm up jog OR sport requirement specific warm-up: 1. Five side line to side line lateral shuffle (defensive position – one minute rest between sets) 2. Four full court sprints with progressions (one minute rest between sets) 3. Dribbling Progressions a) Dominant Hand b) Non-Dominant c) Cross Over d) Two Ball Dribbling 4. Timed shooting drills – post and guard specific a) 30 seconds b) One minute 5. The Mikan Drill (1 minute)

Soccer Phase 3. 1. Goalie a. Five “ladder” drills i. Goal – PK spot – edge of the 18-yard box ii. Runs completed at 75-85% speed with a 30-second rest in between runs b. Sprints to the corners of the 18-yard box i. Two each way, alternating with 30-seconds rest c. 10 burpees d. 10 barrel rolls on the goal line – standing up in between 2. Field a. Five Box to box runs i. 75%-85% speed with one minute rest in between runs 10

b. Two defensive slides along the front of the 18-yard box i. In a defensive position, do a lateral slide from one end of the box to the other – no rest period c. 10 header jumps (no ball) Phase 4. Each student-athlete will complete a five-minute warm up jog OR sport requirement specific warm-up: 1. Goalkeeper a) Five sprints to the edge of the box, jog back to the goal line (no rest) i) Quick feet ball pick up ii) Student-athlete quickly shuffles feet on the goal line, ATC rolls them the ball for retrieval at the edge of the six-yard box iii) Goalie passes the ball back out to the ATC iv) Repeat ten times b) Placement punts i) Punt three times to central midfield, right midfield, and left midfield c) Jump balls i) ATC throws the ball into the air high enough where goalkeeper has to catch it ii) Repeat ten times 2. Field a) Attacking runs/defensive close outs i) Student-athlete sprint dribbles the ball from between the midline and edge of the 18-yard box and shoots on an open net ii) Jog and dribble back to the midline repeat ten times iii) If the player is a defender, have them sprint from the 18-yard box halfway to the midline and slide tackle OR close out empty space iv) Walk back to the edge of the 18-yard box and repeat ten times b) Cutting drills i) Jog from the endline to the edge of the 18-yard box and cut right at 45 degrees into a sprint for ten yards ii) Jog back to the endline and repeat going left iii) After one rep each way, rest 30 seconds and repeat

Softball Phase 3. 1. Pitcher a. Four pole runs i. 75%-85% speed with two minutes rest in between runs b. PFP runs i. Three, quick runs from the mound to the 1st baseline, bend down to pick up a ball – walk back to the mound ii. Three quick runs from the mound to the 3rd baseline, bend down to pick up a ball – walk back to the mound c. Two sprints to first and two rounding first – walk back to the plate 2. Fielder a. Infield ranging i. Lateral slide from 1st to 2nd in a defensive position b. Outfield ranging

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i. Run from straight center to right foul pole looking back at the plate – walk back to center ii. Run from straight center to left foul pole looking back at the plate c. Two sprints to first and two rounding first – walk back to the plate d. Two feet first slides into second base Phase 4. Each student-athlete will complete a five-minute warm up jog OR sport requirement specific warm-up: 1. Pitchers a) Warm up pitching drills b) Lead off throws for ten rounds c) Live pitching 2. Fielders a) Get up sprints i) Starting on one knee, sprint 30 yards (repeat five times with one minute break) b) Lead offs 15 yards i) Repeat five times with 30 second break 3. Two base running cycles a) Home to 1st base, 1st to 2nd, 2nd to 3rd, 3rd to home – 2 minute break

Volleyball Phase 3. 1. Five “ladder” drills a. Baseline – free throw line – half court – opposite free throw line – opposite baseline b. Runs completed at 75-85% speed with a two-minute rest in between runs 2. Four sets of 30 seconds blocking jumps a. 30 seconds rest between sets 3. 10 burpees Phase 4. Each student-athlete will complete a five-minute warm up jog OR sport requirement specific warm-up: 1. Five-minute pepper drill 2. Blocking technique (start position in middle, outside, middle, right side, middle) 10 times OR defensive movement (right or left back) 20 times – based on position 3. Five-minute serve to zone with a run to base and dig to target

Cheer Phase 3. 1. Five “ladder” drills a. Baseline – free throw line – half court – opposite free throw line – opposite baseline b. Runs completed at 75-85% speed with a two-minute rest in between runs 2. 10 mountain climbers 3. 10 jumping jacks 4. 10 burpees Phase 4. Each student-athlete will complete a five-minute warm up jog OR sport requirement specific warm-up: 12

1. Floor routine a) No stunting or tumbling 2. If floor routine cannot be done on this day; a) 30 sit-up ball tosses i) 1 minute break b) 20 lateral hurdle hops i) 1 minute break c) 20 anterior hurdle hops i) 1 minute break d) 3 x 5 platform box jumps

Steps to reduce exposure to head injuries: The University of Texas at El Paso will continue to emphasize ways to minimize head trauma exposure and will expand its efforts as additional research is conducted to identify best practices for prevention and treatment of concussions. Following are examples of current efforts:  Adherence to the Inter-Association Consensus: Year-Round Practice Contact Guideline  Preseason: For days in which two practices are scheduled, live contact will only be allowed in one practice. A maximum of four live contact practices will occur in a given week, and a maximum of 12 total will occur in preseason. Further, only three practices (scrimmages) will include live contact for greater than 50 percent of the practice schedule.  In-season: In-season is defined as the period between six days prior to the first regular-season game and the final regular-season game (or conference championship game, for participating institutions). There will be no more than two live contact practices per week during this period.  Spring Practice: Of the 15 allowable sessions that may occur during the spring practice season, up to eight practices will involve live contact with only three of the live contact practices to include greater than 50 percent live contact (e.g. scrimmages). Live contact practices will be limited to two in a given week and will not occur on consecutive days. Definitions: -Live contact practice: Any practice that involves live tackling to the ground and/or full speed blocking. Live-contact practice may occur in full-pad or half-pad (also known as “shell,” in which a player wears shoulder pads and shorts, with or without thigh pads). Live contact does not include: (1) “thud

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sessions,” or (2) drills that involve “wrapping up;” in these scenarios players are not taken to the ground and contact is not aggressive in nature. Live contact practices are to be conducted in a manner consistent with existing rules that prohibit targeting to the head or neck area with the helmet, forearm, elbow, or shoulder, or the initiation of contact with the helmet. -Full pad practice: Full-pad practice may or may not involve live contact. Full-pad practices that do not involve live contact are intended to provide preparation for a game that is played in a full uniform, with an emphasis on technique and conditioning versus impact.  Continued emphasis of student-athlete safety as a priority, including an annual meeting of the sports medicine staff and all head coaches and administration, during which the unchallengeable authority of the athletic trainers and team physicians will be clearly articulated.  Provide educational materials to student-athletes, coaches, athletic trainers and athletic administration to certify that they have carefully read, fully understand, and aware of the signs/symptoms of concussions.

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Emergency Action Plan

Emergency Personnel: • Certified Athletic Trainer(s) and athletic training student aide(s) are on site for practices. Physician is onsite or on call for competition. • Additional medical personnel can be summoned from the Larry K. Durham Athletic Training Room during normal business hours, (915) 747-6801 Venue: • Each venue on the UTEP athletic campus has its own EAP in place to help direct EMS personnel to safest and most efficient access points. Emergency Communication: • EMS can be activated via cell phone. • Fixed telephone line in the Larry K. Durham Athletic Training Room, (915) 747- 6801 Emergency Equipment: • AED located either on the field of practice/play or inside the facility that there is a practice or competition. • First aid supplies, crutches, and spine board are located on the emergency field vehicle/ or in the athletic training room Role of First Responders: • Provide immediate care of the injured or ill student-athlete • Emergency equipment retrieved as needed • Activation of Emergency Medical System (EMS) • Contact UTEP PD (915) 747-5611 • Direct EMS to the scene. A student athletic trainer or other team personnel will meet EMS at the appropriate entrance and direct them to the scene. • Remaining medical staff and team personnel will limit scene to medical personnel and move bystanders away from the area • Instruct EMS to take student athlete to Providence Hospital Memorial Campus Red Flags Be aware of the following as they constitute a medical emergency: a. Glasgow coma scale <13 b. Prolonged LOC c. Focal neurological deficit suggesting intracranial trauma d. Repeated vomiting e. Diminishing mental status f. Worsening neurological signs and symptoms g. Spinal injury

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