This report, prepared by Walters Inc. at the request of the University of Maryland, documents the facts and events that led to the death of offensive lineman Jordan McNair. U-Md. board of regents releases report laying out timeline that led to Jordan McNair’s death

An Independent Evaluation of Procedures

and Protocols Related to the June 2018 death

of a University of Maryland

Football Student-athlete

September 21, 2018

Prepared by Walters Inc. - Consultant in Sports Medicine

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WALTERS INC.

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IN SPORTS MEDICINE

Introduction

3

Scope of Work

4

Review of Policies and Practices

9

Emergency Action Plan

9

Exertional Heat Illness

13

Crisis Management Plan

17

Hydration Screening

20

Specificity - Conditioning Program

21

23

The Incident

Specific Comments Regarding Incident

Interviews

34

35

Student-athlete Interviews

35

Coaches Interviews

36

University of Maryland Police Officers/Safety Officers

36

Independent Strength Coaches and Certified Athletic Trainers

37

Additional Noteworthy Comments

37

38

Incidental Review

Concussion Management

38

Sickle Cell Trait Screening

39

Lightning Monitoring

40

Cardiac Screening

41

Monitoring of Turf Temperature

42

Models of Care

43

Current Athletic Model

50

Proposed Medical Model

51

55

Organizational Structure

Associate Athletic Director for Performance Science

56

Assistant Athletic Director for Athletic Training

57

Certified Athletic Trainers

57

Strength and Conditioning Staff

58

Team Physicians

58

New Employee Onboarding

59

Credential Monitoring

59

Nutritional Supplements

59

Staff Education

60

Record Keeping

61

Page 1 of74

On-Campus Medical Clinics

61

Athletic Medicine Review Board

62

Observations

62

Recommendations

67

Discussion

70

Exhibits and Appendices

72

Bibliography

73

Page 2 of74

Introduction

The National Collegiate Athletics Association (NCAA) claims college sports equip young

people with skills to succeed in the classroom in competition, and in life (http://www.ncaa.org/

student-athletes/value-college-sports). The value of sports has long been embroiled in students

as they seek the guidance and instruction sports provide. The NCAA values graduation as important as winning on the playing field. Intercollegiate sports are important venues for studentathlete learning, competition, and success. The NCAA promotes the well-being of student-athletes while learning leadership, confidence,. discipline and teamwork in their respective sports.

Although intended to be a learning experience, collegiate sports are in a tremendous

crossfire today with increased exposure from social and public media, external pressures created

by the the influx of monies being secured by sports, and general concern over compensation and

student-athlete welfare. The death of a football student-athlete at the University of Maryland in

June 2018 is a reminder of the importance of keeping appropriate medical care of student-athletes at the forefront of sports and athletic competition.

While no review is cut and dry within the specific scope of a project, many factors are

unable to be controlled and consequently can effect the objectivity of the process. The inability

to work in a vacuum to conduct such a review independent of the media interest is difficult and

requires diligence of an independent reviewer to ensure a review is representative of fact and not

opinion. Since beginning this project, the discovery and review of documents has been challenged by the inaccurate leaks of information. This report reflects information provided directly

from the University of Maryland athletics administration and from one on one interviews with

the people directly associated with the tragic event on May 29, 2018 that ultimately resulted in

Page 3 of74

an untimely death of Jordan McN air which was later determined to be directly related to heat

stroke.

Heat-related illness requires significant attention as early recognition and treatment is

proven to increase survival outcomes and consequently increasing preventable fatalities. For example, after Korey Stringer's death (August 1, 2001) in a preseason workout, and the subsequent

creation of the Korey Stringer Institute which is dedicated to the increased awareness of heat-related illness, the NFL has reported no exertional heat related deaths since Korey's death in 2001.

According to the Annual Survey of Football Injury Research (http://nccsir.unc.edu/reports/) Table IV -Heat Stroke Fatalities from 2000 to 2017, there have been 49 heat strokes reported from

high schools, colleges, professional sports, and sandlot sports.

Scope of Work

This project is a request by the University of Maryland to review procedures as well as

established policy within the athletics department specific to athletic training and the care of university student-athletes. A call was received the morning of June 13, 2018 to engage Walters Inc.

- Consultant in Sports Medicine to evaluate the incident which occurred on May 29, 2018. A

proposal was submitted, accepted and work on the project was engaged June 25, 2018.

The results of this review are not intended to establish a legal standard of care, but to assist University of Maryland Athletics Department senior administration review of procedures and

protocols that impact the health and safety of student-athletes at the University of Maryland. All

documents provided will be reviewed and compared to established sports medicine industry

standard. Where industry standard does not exist, recommendation on best practices will be pro-

Page 4 of74

vided based on current literature, complete with citations as applicable. A timeline of the project

is presented as Figure 1.

IFigure 1

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JUNE

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JULY

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AUGUST

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SEPTEMBER

The University of Maryland's Office of General Counsel and Department oflntercollegiate Athletics directed as follows:

a) perform an independent evaluation ofICA's procedures and protocols related to the June

2018 death of an University football player as detailed more specifically in Exhibit A

("Scope of Services").

b) review the football program's procedures and protocols involving student-athlete health

and safety applicable to:

( 1) planning and conducting team conditioning and practice sessions and

(2) for responding to health emergencies during or after those sessions.

In order to establish context, it is important to understand heat stroke. Exertional heat

stroke is a medical emergency and the most severe of exertional heat illness. Signs and symptoms of exhertional heat stroke can be characterized by a varied presentation of the symptoms,

with the two main criteria being rectal temperature greater than 104-105AdegF (40AdegC) and central

Page 5 of74

nervous system dysfunction (irrational behavior, irritability, emotional instability, altered consciousness, coma, disorientation or dizziness). Additional symptoms can include headache, confusion, nausea or vomiting, diarrhea, muscle cramps, loss of muscle function/balance, inability to

walk, collapse, staggering or sluggish feeling, profuse sweating, decreasing performance or

weakness, dehydration, dry mouth, thirst, rapid pulse, low blood pressure, and quick breathing

(https ://ksi. uconn.edu/emergency-conditions/heat-illnesses/exertional-heat-stroke/heat-strokerecognition/).

Acclimitization is vital to prevent exertional heat illness. The gradual increase in practice

intensity and equipment worn has been established to address acclimitization. Increasing breaks

with modification of the work-to-rest ratio also help with acclimitization.

The recognition of exertional heat illness includes critical components of identification

including profound central nervous system dysfunction and elevated core temperature greater

than 105AdegF. Rectal temperature is an accepted method and the gold standard of obtaining an

immediate and accurate measurement of core body temperature in an exercising individual.

Once the exertional heat stroke is identified, aggressive treatment must be ensued to lower core

body temperature to less than 102.5AdegF within 30 minutes. Cold water immersion is the most effective means to treat a patient with exertional heat stroke.

This evaluation addresses specific procedures including implementation, comprehension,

and compliance of established policies. This report excludes any assessment of specific personnel and consequently does not include any recommendations associated with staffing. The essential steps identified to complete this report included the following:

Page 6 of74

1. Establish a timeline to review University documents provided regarding athletic training

policies and procedures,

2. Schedule interviews with staff that were present at the time of the incident until transfer to

advanced medical personnel.

3. Arrange a trip to College Park, Maryland July 18 -20, 2018 to allow familiarity of the scene,

review videos, and talk with personnel -directly associated with the event to further establish

a more accurate timeline of events. Initial interviews with staff members were conducted at

this time.

A general introductory in-person meeting was held with the Athletic Director and Senior

Associate Athletic Director/Internal Operations in order to introduce the consultant to the Assistant Athletic Director - Director of Football Performance, Assistant Athletic Director for Athletic Training, Associate Athletic Director for Sports Performance, Head Football Athletic Trainer, and two Assistant Athletic Trainers. All of these personnel except the Athletic Director and

Senior Associate Athletic Director/Internal Operations were on the field for the incident of May

29, 2018. Follow up individual sessions were scheduled to allow the consultant to ascertain information specific to the development of the timeline of events. Based upon initial document

review and work to establish a timeline, four immediate concerns were identified and shared

with the senior administration July 27, 2018. Due to the timely nature of the procedures, and

concern for the start of the new academic year and initiation of team practice sessions, an intermediate verbal report was given to allow critical procedures to be immediately addressed.

Page 7 of74

1. The injury evaluation did not include any assessment of vital signs. Specifically, core temperature was not established which ultimately is a critical part in identifying a rapid decline in the

athlete's physical state.

2. Treatment provided did not appropriately address the escalating symptoms of heat-related illness. The prehospital care of exertional heat illness should include rapid recognition and

treatment of signs and symptoms associated with this condition. No vital signs were noted

including core temperature.

3. No apparatus was used for prompt cooling of the patient May 29, 2018. This is discussed in

the literature as best practice and needs to be part of the University of Maryland Sports Medcine Services Staff Manual. The current procedures does not include core temperature assessment but does include aggressive cooling in the event of an identified exertional heat illness.

4. Failure to provide directions to EMS to the scene and designate an individual to flag down

EMS and direct to scene. There was confusion as EMS arrived in the Gosset parking lot while

the target point was the field level driveway as referenced in the EAP in the 2017-18 Med

Manual E-Book and Staff Administration E-Book.

5. Once the patient's condition deteriorated, and respiratory aids were needed, the trauma bag

had to be retrieved from the practice area as equipment (manual suction or oxygen) was not

available in the Gosset Athletic Training Room.

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Review of Policies and Practices

The following policies were reviewed to compare to best practices. The policy design

and implementation relevant to sports medicine was the purview of the Assistant Athletic Director for Athletic Training. As he and the team physicians noted, there is significant input from

several staff members. Although the content in the "e-book" is a comprehensive and thorough as

it pertains to policies and procedures, it is also a cause of significant complication related to its

600-plus pages. The current collection of procedures is difficult to navigate due to the enormity

of the document and consequently makes it difficult to ensure employee retention of these policies.

A printed copy of the University of Maryland Sports Medicine Manual (2017-18 Sports

Med Manual E-Book and Staff Administration E-Book_downloaded_08_08_2017) was accessed

for review. A printed copy of this document was provided by Associate Athletic Director for

Sports Performance during our initial meeting in New Orleans on June 26, 2018. The manual

appears organized. Per the Scope of Work, the manual was reviewed for completeness and content relative to sports medicine, athletic training, and strength and conditioning industry best

practices. The review team of physicians, athletic trainers, and strength and conditioning specialists were utilized to reference current procedures within the University of Maryland athletics.

Emergency Action Plan

The University of Maryland Sports Medicine Emergency Action Plan (EAP) meets

guidelines but staff failed to implement established best practices guidelines (Andersen, Courson,

Kleiner, & McLoda, 2002):

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1. A comprehensive written EAP has been developed by the University of Maryland Athletic

Department.

2. The EAP identifies the personnel involved in executing the plan.

3. The individuals involved in carrying out the EAP have been trained in automatic external defibrillation, cardiopulmonary resuscitation, first aid, and prevention of disease transmission.

There is no evidence or documentation of training and practice of the EAP. Specifically,

when interviewing Assistant Strength Coaches on August 2, 2018, there was no recall of EAP

training for their staff.

4. Specific emergency equipment needs to be identified and validated daily for readiness and

availability. According to the University of Maryland Staff Manual, the following equipment

will be available on-site at every practice session:

a. Athletic Training Kit

b. Emergency phone numbers and student-athlete emergency information

c. Land-line or cell phone and/ or 2-way radio/ walkie-talkie (no radio communication was

available for this incident)

d. Water

e. Ice Bags

Items included in the Trauma Bag utilized on May 29, 2018 were reported as:

a. AED w/ Back Up Pads

b. Oxygen Tank

c. Oxygen Masks

d. EpiPen

Page IO of74

e. Inhaler

f.

Inhaler Spacer

g. Glucose Tablets/Gel

h. Blood Pressure Cuff

1.

Stethoscope

J.

Pulse Oximeter

k. Gloves

I.

Sterile Gauze

m. Thermal Blanket

n. CPR Masks

0.

Artificial Airways

p. Scissors

q. Bag Valve Mask

r.

Manual Suction

s. Peak Flow Meter

t.

Cervical Collar

u. Razor

v. Towels

w. Copies of EAPs

The following items were not available and should be added:

Page 11 of74

a. Tub suitable for cold water immersion (The Heat Illness Management Plan does reference use of active cooling treatment via cold waters immersion for the treatment of heat

stroke).

b. Rectal thermistors

c. Access to copious ice on-site

4. The EAP should include emergency equipment that may be needed for appropriate care including the location of the equipment.

5. The EAP identifies a clear method for communication to the appropriate emergency care

providers and identifies the mode of transportation that should be requested for an injured

patient.

Though the EAP meets standards, there are some concerns outlined as follows regarding

implementation of the EAP on May 29, 2018:

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Hospitals for referral of specific injuries or illness should be part of the EAP (Washington

Aventis or other appropriate facility).

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Details of this EAP were not followed including sending staff person to meet EMS.

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The EAP was not initiated in response to the presentation of escalating symptoms of exertional heat illness.

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A critical component of the EAP is communication of the plan and practice of the plan. There

should be detailed sessions of education, training, and practice specific to the EAP. This

must be orchestrated and appropriately planned for all parties involved in care including

coaches and administrators. All training sessions should be logged and recorded if possible

to allow further review and creation of plans to address deficit or negligent care areas.

Page 12 of74

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The inclusion of a coverage model requires the creation of a document description of roles,

expectations, and implementation of the EAP. It also allows for training plans and validation

of the educational process. The EAP is critical to emergency care. The coverage model A*

should be a written understanding of all roles and responsibilities of personnel relative to incidents occurring within the department. The coverage model provides a document of understanding for administrators, coaches and healthcare providers specific to responsibilities related to emergency incidents. This document should be a dynamic document;

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The daily administration of a "medical timeout" will facilitate daily review of the EAP with

any last minute changes.

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The EAP should include location of AEDs at all venues. The AEDs should be strategically

located to accommodate a three-minute response time for all sites.

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Finally, the last component of the EAP is the communication of the plan to all parties including the care team, local police, fire fighters, EMS and administrators. This should be a living

document with updates as indicated specific to facility modifications, construction, or other

impending situations.

Exertional Heat Illness

Standards for core temperature assessment and utilization of cold water immersion in the

event of exertional heat stroke were requested from a variety of collegiate and professional sports

teams. Athletic trainers and other allied health care professionals should use best practices to

establish onsite EAPs for their venues and athletes. The primary goal of athlete safety is addressed through the appropriate prevention strategies, proper recognition tactics, and effective

treatment plans for Exhertional Heat Illness (EHi). Athletic trainers and other allied health care

Page 13 of74

professionals must be properly educated and prepared to respond in an expedient manner to alleviate symptoms and minimize the morbidity and mortality associated with these illnesses (Casa

et al., 2015).

Exertional heat stroke (EHS) is one of the most common causes of sudden death in athletes. It also represents a unique medical challenge to the prehospital healthcare provider due to

the time sensitive nature of treatment. In cases ofEHS, when cooling is delayed, there is a significant increase in organ damage, morbidity, and mortality after 30 minutes, faster than the average

EMS transport and ED evaluation window (Belval et al., 2018).

Certified athletic trainers and other allied health providers should use these recommendations to establish on-site emergency plans for their venues and athletes. The primary goal of athlete safety is addressed through the prevention and recognition of heat-related illnesses and a

well-developed plan to evaluate and treat affected athletes. Even with a heat-illness prevention

plan that includes medical screening, acclimatization, conditioning, environmental monitoring,

and suitable practice adjustments, heat illness can and does occur. Athletic trainers and other allied health providers must be prepared to respond in an expedient manner to alleviate symptoms

and minimize morbidity and mortality (Binkley, Beckett, Casa, Kleiner, & Plummer, 2002).

Compared with rectal temperature (the criterion standard), gastrointestinal temperature

was the only other measurement that accurately assessed core body temperature (Casa et al.,

2007). Oral, axillary, aural, temporal, and field forehead temperatures were significantly different

from rectal temperature and, therefore, are considered invalid for assessing hyperthermia in individuals exercising outdoors in the heat (Casa et al., 2007).

Page 14 of74

Ice-water immersion and cold-water immersion are recommended for treating the hyperthermic individual (Clements et al., 2002). Case reports show that immediate and continual dousing of the patient, combined with fanning and continually rotating cold, wet towels, represents a

viable alternative until advanced cooling is possible (McDermott et al., 2009).

Some student-athletes may be more susceptible to heat illness. Susceptible individuals

include those with sickle cell trait, inadequate acclimatization or aerobic fitness, excess body fat,

a history of heat illness, a febrile condition, inadequate rehydration and those who regularly push

themselves to capacity. Also, substances with a diuretic effect or that act as stimulants may increase risk of heat illness. These substances may be found in some prescription and over-thecounter drugs, nutritional supplements and foods (Binkley et al., 2002). There should be a standard procedure for the annual education of student-athletes utilizing any stimulant medication or

related medication with potential impact on heat tolerance or other indications for exercise tolerance. This should be appropriately documented in the medical file.

Treatment for heat exhaustion includes: removal from activity, taking off all equipment

and placing the student-athlete in a cool, shaded environment. Fluids should be given orally.

Core temperature and vital signs should be serially assessed. The student-athlete should be removed from the environment and cooled by fans and ice towels, and use of IV fluid replacement

should be determined by a physician (Casa et al., 2015).

Treatment for heat stroke includes: activation of the EAP, assessment of core temperature/vital signs and immediate cooling of the body with cold water immersion (Belval et al.,

2018; Casa et al., 2015). The NATA's Inter-Association Task Force recommends "cool first,

transport second" in these situations (Parsons, 2015). The prehospital care of exertional heat ill-

Page 15 of74

ness should include rapid recognition of exertional heat stroke in those athletes that have collapsed to aggressively recognize signs and symptoms often associated with exertional heat illness. Exertional heat stroke often present with classic signs ofhyperthermia (over 40.5Adeg Cl

104.9Adeg F) and central nervous system dysfunction. The core temperature is best assessed with

assessment ofrectal temperature (Belval et al., 2018; Casa,Armstrong, Ganio, & Yeargin, 2005;

Casa et al., 2007; Casa et al., 2015; Parsons, 2015). In the event ofhyperthermia, the patient

should be cooled immediately (within 30 minutes of presentation) until rectal temperature approximates 38.6Adeg C/101.5Adeg F (Belval et al., 2018).

The University of Maryland Sports Medicine Heat Illness Management Plan meets established best practices guidelines in the following areas:

1. The categories of exertional heat illness are identified.

2. The responsibilities of the athletic training staff are identified in regards to the recognition

and management of exertional heat illness.

3. Athletic department staff members (athletic training, strength and conditioning coaches)

provide education on hydration levels and techniques.

4. Fluids are accessible to student-athletes in order for them to meet appropriate hydration levels.

5. A heat illness risk factor scale is included in the policy.

6. The policy includes Wet Bulb Globe Temperatures and heat index levels that may increase

the risk of exertional heat illness.

7. Emergency care for exertional heat illness is included.

Page 16 of74

Though the exertional heat illness procedure meets standards, there are some concerns

outlined as follows regarding implementation of care on May 29, 2018:

aC/

The monitoring of Wet Bulb Globe Index addresses best practice within exertional heat illness. Though Wet Bulb Globe Index is identified as best practices, no measures were recorded at the University of Maryland on May 29, 2018. Weather statistics were obtained from

WeatherOps. There was a failure to obtain venue specific weather statistics.

aC/

There was the failure to identify escalating symptoms associated with exertional heat illness

including removing the athlete from the field, assessing vital signs, and identifying the condition and aggressively treating the patient's elevated core temperature.

aC/

Equipment specific to the EAP should include a trauma bag for each venue. A cold water

immersion device needs to be established for each conditioning and practice activity. This

equipment is part of the appropriate care to allow for rapid cooling of exertional heat illness

once identified.

Crisis Management Plan

The University of Maryland Athletic Department's Catastrophic Incident Guideline meets established National Best Practices Guidelines in the following areas:

1. An incident( s) that can be classified as a critical incident is defined.

2. A critical incident management team has been established. The following are listed as members of the University of Maryland Athletics Critical Incident Management Team:

a. Director of Athletics

b. Assistant Athletic Director for Athletic Training and Medical Services

c. Associate Athletic Director / Director of Sport Performance

Page 17 of74

d. Head Team Physician

e. Deputy Director of Athletics / Chief Operating Officer

f.

University General Counsel

g. University Counseling Center Director

h. Additional personnel deemed appropriate by Critical Incident Management Team

3. An immediate action plan has been established in the event of a catastrophic incident.

4. A chain of command as well as action plans for the Critical Incident Management Team is

documented in the guideline.

5. The guideline includes action items in the event that the Critical Incident is considered a

criminal offense.

6. The guideline includes action items in the event that the Critical Incident occurs during team

travel.

7. A written summary chronicle for the Critical Incident is included in the guidelines.

The event that occurred on May 29, 2018 is considered a catastrophic event per the University of

Maryland Athletics Critical Incident Guideline. The following items did not occur per the University of Maryland Athletics Critical Incident Guideline:

1. Timely documentation of the event did not occur (meeting conducted on June 11, 2018).

There were five certified athletic trainers on the field during the incident. Individual accounts of the events were requested and provided upon request. During the meeting with the

Assistant Athletic Director for Athletic Training (New Orleans), it was commented that the

Head Football Athletic Trainer generally enters all injuries into the injury management program.

Page 18 of74

2. Immediate communication with the Critical Incident Management Team did not occur.

However, it should be noted that the Head Team Physician was notified at 5:52pm. The Associate Athletic Director / Director of Sports Performance and the Sport Administrator were

contacted by the Director for Athletic Training and Medical Services "once things settled

down in the Emergency Room."

3. There is no documentation available to determine when the following members of the Critical Incident Management Team were notified:

a. Deputy Director of Athletics / Chief Operating Officer

b. University General Counsel

c. University Counseling Center Director

4. There is no documentation available to determine when the following University officials

were notified as stated in the guidelines:

a. President of the University

b. NCAA Faculty Athletics Representative

c. University Legal Counsel

d. USU Risk Management

e. Vice President for Student Services

f.

Parent Resource Center

5. A detailed written summary chronicle was not prepared following the catastrophic event as

the Guideline requires. There is evidence of written documentation of the actual student-athlete event prepared by each member of the Athletic Training staff that were part of providing

care to the student athlete.

Page 19 of74

The policy as presented meets expectations and is well written. The policy as written was

not followed post-event.

Hydration Screening

1. There is no evidence of a written hydration screening procedure in the Sports Medicine staff

manual.

2. There is no evidence of a written hydration screening procedure in the Strength and Conditioning staff manual. Practices were reported as follows:

a. Green: 1.00 - 1.019 equates to cleared to practice; continue hydrating.

b. Yellow: 1.020 - 1.029 equates to monitor at practice; modifications as needed; continue

hydrating.

c. Red: > 1.030 equates to practice modifications; at the discretion of sports medicine staff,

hold from practice; continue hydrating.

4. Strength and Conditioning and Athletic Training staffs comment during on-campus interviews that hydration testing is conducted prior to in-season football practices.

5. Strength and Conditioning and Athletic Training staffs comment during on-campus interviews that hydration testing was not conducted for conditioning activities prior to May 29,

2018.

6. Hydration testing is conducted by the Strength and Conditioning staff for football.

This is a concern as non-credentialed persons are conducting testing with significant impact (urine specific gravity) in the absence of training standards. The National Wrestling Coaches Association requires completion ofwebinar training of qualified credentialed healthcare professionals (nutritionist, physician, certified athletic trainer, etc.). The current level of hydration

Page 20 of74

for collegiate wrestlers is specific gravity of 1.02, a well hydrated level. Hospital or clinical laboratory report their lowest hydration level as 1.025. The National Wrestling Coaches Association

webinar is recognized by the NCAA as a standard for all personnel dealing with body composition and hydration levels of student-athletes.

Hydration testing is an excellent addition to pre- and post-activity weight charts to monitor fluid loss. However, it is recommended any testing by personnel have appropriate training to

validate clinical processes.

Specificity - Conditioning Program

The NATA Heat Illness Recommendations (Casa et al., 2015) and Guideline lA of the

NCAA's 2014-15 Sports Medicine Handbook recommends the student-athlete should be protected from premature exposure to the full rigors of sports. Optimal readiness for the first practice

and competition is often individualized to the student-athlete rather than a team as a whole.

However, there is a lack of scientific. evidence to set a specific number of days of sport practice

that is needed for the first sport competition (Parsons, 2015). It is also recommended "that student-athletes should participate in at least six to eight weeks of preseason conditioning. Gradual

progression of type, :frequency, intensity, recovery and duration of training should be the focus of

the preparation segment. In addition to these areas warranted for progression, 10 to 14 days are

needed for heat acclimatization when applicable (see Guideline 2C)". This recommendation is

intended for preseason football practice.

The following information is a summary of the conditioning program that was established

by the University of Maryland Strength and Conditioning staff and distributed to the football roster for the month of May.

Page 21 of74

1. The weeks of May 1 - 28, 2018, were determined to be used as a NCAA discretionary period

for the University of Maryland football team.

2. The month of May workout schedule is prepared by the Strength and Conditioning staff and

is issued to football team members via email. Text messaging was also utilized by the

Strength and Conditioning staff in order to remind the team members to refer to the schedule.

The May schedule included basic tips for training, nutrition, sleep, flexibility, and progression in a format that should be easily followed by a collegiate student-athlete.

3. The May schedule included "goals expected to be achieved first week back." Included in the

goals is 10 x llO's with subsequent completion times (:19 seconds for offensive linemen),

and a 60 second rest period between each repetition.

4. A calendar for the month of May is prepared by the Strength and Conditioning staff and accompanies the schedule that is distributed to members of the football team. The May calendar includes recommended points of emphasis for each day. The 10 x 110 's is included on

the calendar for the May 29th team run.

5. The team schedule includes recommended daily exercises to be performed along with daily

sets and repetitions.

6. A dynamic warm-up plan is included in the materials distributed to football team members.

The dynamic warm-up was conducted by the team prior to the 10 x 110 test on May 29th.

7. The team schedule includes recommended daily recommended running workouts.

8. Text messages and emails were sent to the football student-athletes regarding the May Take

Home Plan. Each e-mail included the Plan as an attachment.

Page 22 of74

The Incident

Jordan McNair enrolled at the University of Maryland in the summer of 2017. On his

pre-participation physical examination it is noted he has a Vitamin D deficiency and was also on

a prescription ofVyvanse capsule (50 mg dose). Vyvanse is a stimulant medication used to treat

Attention-Deficit/Hyperactivity Disorder (ADHD). Several intrinsic factors that increase risk for

Exertional Heat Stroke (EHS) include medications/supplements (e.g., diuretics, antihistamines,

CNS stimulants, antidepressants). While requested, no toxicology results were made available.

Records indicate this was dispensed by the patient's personal physician on a monthly basis. There is general concern among the medical community for student-athletes involved in

physical activity while taking stimulant medication, though no precautions are generally listed on

the drug information sheets.

In talking with the Head Team Physician, the following statement is generally included

with student-athlete education specific to stimulant medication:

The team physician stated "all of our athlete's that are on stimulant medication for

ADHD must meet at least annually to review their medication , assess any side effects and discuss follow up plans with their prescribing physician. All known common and serious adverse

reactions are discussed at that time. This is also discussed during follow up visits for those athletes that are prescribed a stimulant medication by a UM sports medicine physician. "

Jordan McNair's initial pre-participation medical examination was conducted April 22,

2017. The Head Team Physician confirmed that student-athletes with specific medications are

educated about effects of medications (see italicized statement above), and encouraged to ask

questions about the medication. No records were provided of any counseling or patient educa-

Page 23 of74

tion relative to impact of the drug on exercise tolerance for Jordan McNair. As this was not

specifically documented, validation that this occurred is not possible and will be recommended

as a step going forward. This recommendation was mutually discussed and supported by the

Head Team Physician and consultant.

Student-athletes are weighed daily for all practice sessions. Specific questions were directed to football coaches and strength coaches about Jordan McNair's weight. As a position

group, offensive linemen often struggle with their weight. Coaches alluded to discussions about

body weight of players during personnel meetings, but none recalled any specific "red alert" for

this student's weight. Jordan's weight in June 2017 was 332 pounds, 326 in summer of 2017,

340 in January of 2018, and 334 in the winter of 2018. The spring game was conducted on April

9, 2018, and the following weights are reported following spring practice. Jordan's position

coach was asked about Jordan's weight as an issue, and he responded there was no concern. According to both Assistant Athletic Director - Director of Football Performance and the Offensive

Line Coach, Jordan McNair was not on an improvement plan for his weight though his coach did

comment his target weight for reporting in August was 325 pounds (sixteen pounds below the

pre-workout weight of May 29, 2018). All data is presented below in Table 1.

Table 1. Jordan McNair Weights

(taken from Strength_Jordan_Assessments_timepoints_Court)

T

329

w

327

330

326

329

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Table 1. Jordan McNair Weights

(taken from Strength_Jordan_Assessments_timepoints_Court)

Table 1 includes Jordan McNair's weight for the weeks prior to the incident. The team

had their discretionary time off from May 4 to May 29, 2018. According to the NCAA, studentathletes enrolled in summer school, or who meet certain academic requirements, may engage in

required weight training, conditioning, and review of practice and game film for up to eight

weeks during the summer vacation period. These weeks do not have to be consecutive, and activity during this period is limited to a maximum of eight hours per week with no more than two

hours per week spent on film review. Countable coaches may be present and involved with any

required weight lifting, conditioning, and/or film review.

The strength and conditioning staff sent reminders to the team during the time away reminding them of the need to continue conditioning and also the parameters of the test to be administered upon their return to campus May 29, 2018. Jordan did gain weight during his time

off, and reached his highest weight of the spring, 341 pounds (a 5% gain in body weight in the

last thirty days).

The conditioning session was initially scheduled for the Maryland Stadium but was

moved due to construction. The second option was the Cole Field House, but this was changed

due to the poor availability of field space. Thus the decision was made to move to the practice

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fields. The staff was now pressed to get the field setup due to the last minute change in venue.

Although change of venue is not uncommon in outdoor sports, it is essential that sufficient time

must be allowed to ensure minimal medical equipment is setup by the athletic training staff prior

to practice initiating

The Head Football Athletic Trainer had identified three new student-athletes a n d student-athletes as concerns for the workout. He closely monitored their

activity.

The team conditioning session was scheduled for 4:15 pm on May 29, 2018. Hydration

stations were established around the field to allow copious access to fluids. The following timeline was established from multiple data points.

At 12:43:57 pm on May 29, Jordan McNair accessed the locker room as was identified on

the digital key pad.

There were five certified athletic trainers positioned on the turf practice field. The Head

Football Athletic Trainer and two Assistant Athletic Trainers were positioned along the end zone

adjacent to the Team Field House (see figure). There were two students to assist with hydration

of players. The Assistant Athletic Director for Athletic Training, an Assistant Athletic Trainer,

and three students were positioned along the end zone adjacent to the grass fields.

From the street view (disk I of 3), the practice field can be seen. Only the even repetitions are visible from the street camera used to create the timeline. At 16:09:00, the football

players starting to gather on the practice field. At 16:13:00 the players begin their workout. It is

noted at 16:24:00 that the team flexibility and dynamic warmup activities are engaged. At

16:38:39, players lineup to begin the testing phase of the workout. The team was divided into

Page 26 of74

three groups of skill athletes,

big skill athletes, and linemen. Jordan McNair was

part of the third group. Each

of the groups ran 10, 110

yard runs. The completion

time allotted for the linemen

was nineteen seconds. The

first group ran their first repetition at 16:40:00. The linemen group ran their first repetition at 16:41 :00. It was reported by

strength coaches that Jordan McNair completed his first seven runs within his allotted time. Prior to the eighth repetition (16:53:00), he was reported by the Athletic Trainers as exhausted.

During the run, the Head Football Athletic Trainer noticed athletes that were complaining

of fatigue. The team encourages active recovery and avoiding bending over with fatigue, and

prevention of blood pooling in legs. Athletes were encouraged to "stand tall" during rest intervals.

At 16:54:25, the linemen complete their eighth repetition. The final repetition by the

linemen was at 16:58:45. Teammates saw Jordan McNair effort and went to run with him and

encourage him to complete the repetition. At 16:59:38, Jordan McNair is being assisted upper

left comer of the video. He was being cared for by the certified athletic trainers on the field who

described cooling and hydration of the athlete.

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The Assistant Athletic Director for Athletic Training documented the incident in Presagia

as follows:

S: fatigue, back pain, back cramps

0: hyperventilation, profuse sweating, back cramps

A: heat cramps, fatigue, hyperventilation. Possible seizure added as an addendum to

his first note. (This note references the activity occurring within the Gosset Athletic Training

Room.) No other documented differential diagnosis.

The Head Football Athletic Trainer documented the incident in Pressagia as well as written documentation:

S: low back pain and cramping

0: oral hydration, ice packs, ice/cold towels used for cooling

A: no documented assessment

The Assistant Athletic Trainers reported:

1. Jordan did not mention cramps on the field. "I'm just tired."

2. Dizziness.

3. No documented assessment

The second Assistant Athletic Trainer reported from written documentation:

S: c/o low back pain

0: No documented assessment

The third Assistant Athletic Trainer was not involved with the on-the-field care nor the

initial athletic training room care that Jordan received. His involvement included the retrieval of

Page28 of74

emergency equipment as well as meeting EMS on the top floor of Gosset. No documented assessment was provided by the third Assistant Athletic Trainer.

At the end of the run, one athlete had requested his inhaler and it was obtained by the

Head Football Athletic Trainer from the Gator (parked between the fields). The. inhaler was kept

in the trauma pack on the Gator. The Head Athletic Trainer noticed Jordan McNair being assisted by two Assistant Athletic Trainers. He yelled to them to continue him moving (to continue

active recovery). The specific verbiage from the Head Football Athletic Trainer could not be

confirmed from interviews. The team was transitioning to drill work on the grass fields, and the

Head Football Athletic Trainer began moving that way, in a backward walking to ensure all players were moving toward the grass fields. All players were moving that direction except Jordan

McNair, who was still being assisted by the two Assistant Athletic Trainers, and the Assistant

Athletic Director for Sports Medicine was approaching. Assistant Athletic Trainers assisting

with the care of Jordan McNair were questioned about skin temperature and neither noticed any

elevation in skin temperature, and denied any observation of increased skin temperature. The

two Assistant Athletic Trainers eventually began to walk Jordan McNair to the position drill area.

The Head Football Athletic Trainer continued to move toward the grass fields, and a student informed him of another player feeling dizzy. The Head Football Athletic Trainer addressed the

athlete at his group (linebackers). Athletic Trainers notice Jordan was complaining oflow back

tightness and cramping. The Athletic Trainers described hyperventilation. He was encouraged to

slow controlled breathing and walk around the field with active recovery. The athlete was

walked toward the shed and was put on a treatment table with his legs elevated. At this time, the

Head Football Athletic Trainer noticed the two Athletic Trainers taking Jordan McNair from the

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field in the Gator. The Head Football Athletic Trainer called by cell phone to check on the status

of the player and upon learning he was improving per the Assistant Athletic Trainer, the Head

Football Athletic Trainer stayed with the remaining players on the field. At the end of drills, the

player being attended to in the shed was transitioned to another Assistant Athletic Trainer, and

the Head Football Athletic Trainer ran down to the Gosset Field House.

At 17:22:12, McNair taken from field via Gator by the Assistant Athletic Director for

Athletic Training and an Assistant Athletic Trainer. The time from onset of symptoms to being

removed from field was a total of 34 minutes. At 17 :25 :20, the Gator turns comer to Gosset. The

Gosset Training Door Report shows the building being accessed by the Assistant Athletic Director for Athletic Training from the Maryland Stadium field level at 17:26:05.

The Head Football Athletic Trainer entered Gosset via the stadium field level athletic

training room door where he saw Jordan McNair being attended by the Assistant Athletic Director for Sports Medicine. Jordan McNair was reported as walking into Gosset. His condition was

reported as mostly low back cramps and being uncomfortable. The athlete was placed on the

large mat table to attempt supine positioning with legs elevated. The Head Football Athletic

Trainer instructed Assistant Athletic Trainers to get cold towels to cool him and help with cramping. Jordan continued to be uncomfortable, and sat up on his own as reported by the Head Football Athletic Trainer. He stood and wanted to walk around to relieve back symptoms. He got up

up to walk around, and went back to the back physician office area where he sat on the treatment

table. When questioned about skin temperature, the Assistant Athletic Director for Athletic

Training denied noticing hot skin.

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He sat on the table, and the athletic trainers were providing oral hydration and cooling

with ice/cold towels and suddenly demonstrated a drastic mood change. At 17:50:00, Jordan

McNair had mentalA*status change, began yelling at the Atheltic Trainers.

The Head Football Athletic Trainer noticed this and instructed the Assistant Athletic Director for Athletic Training to call EMS. The Assistant Athletic Director for Athletic Training

telephoned the team physician at 17:52:00, instead of calling 911. The Team Physician instructed

the Assistant Athletic Director for Athletic Training to call 911, which was done at 17:55:00.

There was a subsequent seizure coupled with difficulty breathing due to airway obstruction (mucous described as a brown foamy sputum). He was positioned in a side recovery position. The

Head Football Athletic Trainer used manual suction from trauma bag due to airway compromise.

The athletes jaw was, clenched and he was having convulsive movements as described by Head

Football Athletic Trainer. Oxygen was administered.

The Head Football Athletic Trainer was questioned about why the decision to not utilize

the cold whirlpool to cool Jordan McNair following the change in status and seizure activity. He

answered due to the concern of size of the student-athlete and the smaller stature of the athletic

trainers providing care, there was fear of drowning. Cooling was attempted with cold towels and

ice packs to the groin and axilla.

At 18:02:00, the Head Football Athletic Trainer called to campus security and alerted of

respiratory distress, to make sure Advance Cardiac Life Support (ACLS) personnel were dispatched - and confirmed EMS had been dispatched. At 18:06:00 the dispatcher initiates priority

response since patient seizing. The Head Football Athletic Trainer asked the Assistant Athletic

Director for Sports Medicine if someone had been sent to meet EMS. As no one had, the Head

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Football Athletic Trainer went to the alley adjacent to the Gosset Team House (field level) to direct EMS, but did not hear or see them at that point. Two student managers were instructed to

walk up the alley toward the field house drive and flag down EMS. The Head Football Athletic

Trainer returned to the patient to see the first ambulance inside, as they had accessed the building

from the main entrance on the first floor and taken the elevator to the ground floor.

Video and audio calls indicate the first ambulance and University of Maryland Police Officer Walker arrived on-scene at 18:03:33.They accessed the building from the ground floor of

Gosset and took elevator to the athletic training room. Jordan McNair is loaded onto the first

ambulance stretcher and moved outdoors. Athletic Trainers are continuing to attempt to cool

with ice packs to the groin and axilla. The Head Football Athletic Trainer confirmed the hospital

for transport and confirmed the need to continue cooling efforts. The paramedic confirmed the

need for cooling, and informed the Head Football Athletic Trainer Washington Adventis had the

"Bear Hugger" for cooling.

At 18:10:57, theACLS ambulance arrives on-scene front of Gosset. At 18:11:44, the

ambulance drives from front Gosset around back to field level. The Head Football Athletic

Trainer secured ice and water in an office garbage can and took to ambulance for continued cooling. The patient is transferred from the gurney of ambulance 1 to the gurney of ambulance 2.

Once in the ACLS ambulance, paramedics work to secure an IV line, while the Head Football

Athletic Trainer and Assistant Athletic Director for Athletic Training continue to assist to cool

patient. At 18:27:03, the ambulance leaves from field level and arrives at WashingtonAdventis at

18:36:00. The following figure includes data from the timeline established by Walters from various data points. The source of the data is included in Appendix A.

Page 32 of74

IFigure 2

6:0lPMEST

, - - - - - - , 1 2ndcalltoUMPD

5:SSPMEST

(911)toadviscof

cautoUMPD(911) respiratoiydistrcss

4:53PMEST

Completed 7th Rep - Exhaustion

andCmnpsRcportcd

4:40PMEST

Start ofTeam Testing

4:20PM 4:30PM 4:40PM 4:50PM 5:00PM 5:10PM 5:20PM 5:30PM 5:40PM 5:50PM 6:00PM 6:10PM 6:20PM 6:30PM 6:40PM

The following findings are based on the above mentioned timeline:

aC/ the time from onset of cramps to being removed from field was 34m 12s;

aC/ the time treated in athletic training room prior to change in stature was 23m 55s;

aC/ the time from 911 call to ambulance arriving at the parking lot in front of Gosset Team House

was 8m 33s;

aC/ the time from the 911 call to departing the stadium was 37m 3s;

aC/ the onset of symptoms to the call to 911 was lh 7m; and

aC/ the time from onset of symptoms following the seventh repetition to departure in the ambulance enroute to Washington Adventis was lh 39m 3s.

Page 33 of74

aC/ The Associate Athletic Director for Sports Performance was notified the evening of May 29 of

the incident.

Specific Comments Regarding Incident

The failure to rapidly recognize exertional heat illness is a concern. The lack of recognition and assessment of the severity of the event delayed cooling the patient in a timely manner.

Even if the symptoms were not identified on the field, if core temperature had been assessed with

the change in mental status at 17:50 pm, there might have been the opportunity to reverse the patient's core temperature. Without knowing the time the temperature became elevated, it is not

possible to say when the condition manifested as exertional heat stroke. The treatment of exertion heat illness involves rapid recognition, rapid assessment, rapid cooling and rapid advanced

care within 30 minutes of the onset of symptoms.

Likewise, the change in practice venue on May 29, 2018 from the Maryland Stadium to

Cole Field House to eventually the practice fields is another contributing factor. Due to the last

minute change, the Athletic Training Staff had to rush to get hydration products and other emergency equipment to the synthetic turf practice fields. Though it is reported cold water immersion

tanks are generally included as part of the field setup, they were not on May 29, 2018. Items included within the EAP must be adhered to daily. Deviation from the EAP creates problems.

The issues related to construction within the Cole Field House added challenges to care.

The traffic changes, reporting of ambulance to the upper parking lot versus the field level, loss of

access to the Gosset Team House; all added to the confusion. The failure to immediately send

someone to meet the ambulance (as is identified within the EAP) is a failure to follow an established plan.

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In review of the incident of May 29, 2018, the Head Football Athletic Trainer noted barriers involved in care provided to Jordan McNair. First, there was a short notice for the change

of venue for the scheduled conditioning run. The complacency of the perceived workout intensity and expected athlete cardiovascular status (level of conditioning) were inaccurate. There was

also an assumption of the mildness of the weather that day and the subsequent mild stress response. The calls to 911 (both the initial call at 17: 56 by the Assistant Athletic Director for Athletic Training and the followup call at 18:03 by the Head Football Athletic Trainer) were made

from the Head Football Athletic Trainer office phone which is across from the physician's examination room. Upon the calls, staff was not sent to escort EMS to the facility upon arrival. Staff

was adequate but limited inside the Gosset athletic training room during the event due to the distance to the practice field. There was also a delay due to campus and Cole Field House construction. The Assistant Athletic Director for Facilities kept the Athletic Training staff abreast of construction limitations. There were instructions on restrictions to access the back door (from the

Athletic Training Room to Maryland Stadium Field level) and this further delayed staff and student returning to the athletic training room post-workout.

Interviews

Student-athlete Interviews

Student athletes were given the opportunity to register for time slots to meet with the interview team to address any questions or concerns relative to the incident. The Assistant Athletic

Director for Equipment shared the announcement with student-athletes, and encouraged signup.

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A total of four student-athletes signed up for meetings with the review team on August 1, 2018.

A compilation of notes from the meetings are summarized in Appendix B.

No names were recorded to provide anonymity. The concerns expressed were very similar in three of four interviewed stating "how hot and humid it was" and general concern for how

this event happened.

Coaches Interviews

Football staff coaches were interviewed individually to ascertain observations from the

field on May 29, 2018. A compilation of notes from the meetings are summarized in Appendix

C.

University of Maryland Police Officers/Safety Officers

The University of Maryland Police Officers were questioned to validate the climate of

activity, coordination of events associated with the EAP, and how construction information is

provided to the Athletic Department. The Police Officers arrived on-site at about the same time

as the first ambulance as was presented in the timeline (Appendix A). The officers are very involved with stadium safety and weather conditions but not necessarily with specific EAPs at the

specific venues. There was a debriefing session between the liaison from University of Maryland Police Department and the athletics department representatives (Assistant Athletic Director

for Athletic Training and the Head Football Athletic Trainer). This is an essential step in ensuring appropriate modifications are made to increase interdepartmental communication.

It was reported that the nature of campus construction is a challenge and the University of

Maryland Police Department disseminates information to project managers and specific departments relative to road closures, building access, and building initiatives. This information must

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be forwarded to the grass-roots level and especially the game managers and administrators and

team lead athletic trainers to incorporate data into the EAP. It is imperative that a representative

of the emergency team be sent to meet EMS and direct the team to the location of the incident

and that appropriate location is communicated to relevance personnel at the time of ambulance

initiation.

Independent Strength Coaches and Certified Athletic Trainers

Interviews were conducted with representative Power 5 certified athletic trainers and

strength coaches to gauge the workout plans (weight training) and the specific testing performed

by University of Maryland football student-athletes on May 29, 2018. Based upon the information provided, further exploration on best practices and industry standards for comparable institutions was conducted.

Additional Noteworthy Comments

There were two additional interviews that were conducted. One was from a parent expressing concern over the pressure her child had endured during time with the football team.

Due to the nature of the interview (not heat related illness related), the information was taken and

passed along to University General Counsel to pass along to the second commission being established to review the football program in general. The second interview was from an athletic

training student expressing concern for the handling of a couple of student-athlete injuries and

the intervention between the Head Football Athletic Trainer and the student.

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Incidental Review

Concussion Management

The University of Maryland Athletics Department Sports Medicine department's Concussion

Policy and Management Plan meet NCAA best practices for Concussion training Diagnosis and

Management. The following criteria items are included:

1. Annual student-athlete education about the signs and symptoms of concussion.

2. A student-athlete who exhibits signs, symptoms or behaviors consistent with a concussion

will be removed from athletics activities and evaluated by a medical staff member with experience in the evaluation and management of concussion.

3. A student-athlete diagnosed with a concussion will be removed from athletic activity for at

least the remainder of that calendar day.

4. Take home instructions for a student-athlete with signs and symptoms of a concussion.

5. Medical clearance for a student-athlete diagnosed with a concussion to return to athletics activity will be determined by a physician or the physician's designee.

6. Procedures are in place for pre-participation baseline testing of each student-athlete.

7. Inclusion of post concussion assessment materials.

8. A progressive plan for return to athletic competition.

9. Coordination of a return to learn management plan.

10. Appropriate documentation of concussion education provided to athletic trainers, medical

staff, coaches, and athletic administrators.

The policy as presented meets expectations. This policy did not impact care to the patient

on May 29, 2018.

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Sickle Cell Trait Screening

The University of Maryland Sports Medicine Department's Policy and Procedure manual contains the following information regarding sickle cell trait. The information reviewed is consistent with current best practices.

1. An introduction to sickle cell trait where the condition is defined.

2. Signs and symptoms of sickle cell trait as well as differential diagnosis for the condition.

3. Emergency management of sickle cell crisis or event.

4. The NCAA information fact sheet regarding sickle cell trait.

5. According to the Sports Medicine Student-Athlete Care and Treatment Guidelines, studentathletes are required to receive sickle cell education and acknowledgement.

6. A student-athlete acknowledgement form where sickle cell trait is defined and signs and

symptoms are listed. The acknowledgement form must be signed by the student-athlete, the

examining physician, and the athletic trainer.

7. A sickle cell trait Educational Acknowledgment form that states that the student-athlete has

"read and fully understands the aforementioned facts about sickle cell trait." This document

also states that the student-athlete has "received a Sickle Cell Education Packet from the

Sports Medicine office."

While the components of best practice are included, the concerns with sickle cell policy

are as follows:

1. The policy and procedure manual does not include the contents of the Sickle Cell Education

Packet that is listed in the Educational Acknowledgment form.

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2. How are strength and conditioning coaches and sport coaches (head and assistants) notified

as to which student-athletes (if any) are sickle cell trait positive?

3. What written documentation are coaches given in regards to sickle cell trait positive studentathletes?

4. What education are strength and conditioning and sport coaches given on sickle cell trait?

5. What education is provided to Sports Medicine staff regarding sickle cell trait and when is

this education provided?

The policy as presented meets expectations. This policy did not impact care to the patient

on May 29, 2018.

Lightning Monitoring

The current athletic department lightning monitoring is based on WeatherOps and the detection

radar system based out of Maryland Stadium. While this works well for activities within the

Maryland Stadium, it is not venue specific for non-football stadium activities including but not

limited to football practice fields, softball, lacrosse, field hockey, baseball and soccer. Lightning

monitoring is also followed by the University of Maryland Police Department specific to game

and event management. The University of Maryland Police Department utilize a 16 mile radius

for announcing weather and mandate evacuation of outdoor sport venues when lightning is within a 10 mile radius. Lighting monitoring currently utilizes the radar at the Maryland Stadium,

and needs to upgraded to allow for venue specific lighting measurements.

The policy as presented fails to meet expectation, and it is recommended the incorporation of venue specific lightning monitoring plans. This policy did not impact care to the patient

on May 29, 2018.

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Cardiac Screening

The University of Maryland Sports Medicine Policy and Procedure manual does not contain a

specific cardiac screening policy. However the following best practice measures for Cardiovascular Care of Collegiate Athletes are in place:

1.

Student-athlete medical history form does include a comprehensive personal and family

history of cardiac events / disease.

2.

Cardiovascular screening is included as part of the Pre-Participation Physical Exam

which is conducted by a Team Physician.

3.

Non-invasive cardiac screening (e.g., Electrocardiogram and Echocardiogram) are not

conducted as part of the pre-participation physical exam.

4.

The Sports Medicine Policy and Procedure manual does contain written procedures for

Electrocardiograms that are prescribed by the Team Physician.

5.

The Sports Medicine Policy and Procedure manual does contain written procedures for

Echocardiograms that are prescribed by the Team Physician.

6.

The University of Maryland Athletic Department has developed an EAP that can be implemented in the event of a cardiac emergency.

7.

The University of Maryland EAP does include the location(s) of Automated External Defibrillators.

The policy as presented meets expectations. This policy did not impact care to the patient on

May 29, 2018.

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Monitoring of Turf Temperature

The University of Maryland forwarded Walters Inc. a request from the DC Safe Healthy

Playing Fields group regarding turf temperature monitoring. The volunteer group seeks to raise

awareness of the problems with artificial turf including environmental concerns and protect the

safety and the finances of our local communities relative to use of synthetic surfaces. The group

is concerned about the health and environmental hazards of synthetic turf, and inquired to Dr.

Loh:

"We are a group of activists concerned about the health and environmental hazards of

synthetic turf We would like the commission to please see whether the turfJordan McNair was

playing on was synthetic turf, and if it was, it will be important to check the temperature records

of the synthetic field. If no surface temperature records are available, we suggest using a handheld infrared thermometer to test the field where he was playing under similar weather conditions. We would also like to know

if the University ofMaryland has a policy in place about play-

ing surface temperatures." This inquiry is included as Appendix D.

At the current time, there was no established best practice for turf monitoring. However,

due to the concern of this group, this data was collected for further consideration. There was no

monitoring of turf, and the response provided is included as Appendix E. The group requested to

collect such data going forward (Appendix F). Based upon their request, team personnel were so

requested to monitor surfaces and are monitoring turf temperatures during preseason practices

(Appendix G).

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Models of Care

The NCAA has been committed to harmonizing practices through policies and guidelines

established to support best practices in sports medicine for collegiate athletes. However, enforcement of these practices is dependent on the universities and NCAA auditing is unrealistic in

the current climate with the volume of institutions versus resource availability. The development

of the role of the "Athletics Health Care Administrator" was to address this specific concern of

ensuring compliance with and knowledge of modifications in the ever changing practices of

medical care for athletes (http://www.ncaa.org/sport-science-institute/athletics-health-care-administration-best-practices-0). The Athletics Health Care Administrator for the University of

Maryland is the Associate Athletic Director for Sports Performance.

It is essential when determining which medical model is most appropriate for an institution, that both independent medical care and autonomy are priorities in the decision-making

process. The concept of independent medical care refers to an environment in which primary athletics health care providers, defined as the team physician and athletic training staff, may make

medical decisions for student-athletes free of pressure or influence from non-medical factors.

This approach empowers team physicians and athletic trainers to have final decision-making authority regarding the diagnosis, management and return-to-play determinations for student-athlete care without influence exerted by non-medical professionals, such as coaches or athletics

administrators.

Independent medical care in sports developed from the first Safety in College Football

Summit held in January of2014 to address concussion care and independent medical care in college sports. The groups that participated included the American Academy of Neurology, the

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American College of Sports Medicine, the American Association of Neurological Surgeons, the

American Medical Society for Sports Medicine, the American Orthopaedic Society for Sports

Medicine, the American Osteopathic Academy of Sports Medicine, the Collegiate Athletic Trainers' Society, the Congress of Neurological Surgeons, the NCAA Concussion Task Force, and the

Sports Neuropsychology Society. From the summit, organizations formerly established their

commitment to principles of independent medical care in the 2014 document, Inter-association

Consensus: Independent Medical Care for College Student-Athletes Guidelines. The document

was reviewed during the Second Safety in College Football Summit (February 2016), and an updated and endorsed inter-association document was published. At the 2016 NCAA convention,

the five NCAA Division I conferences with autonomy passed Proposal 2015-15 (independent

medical care) reflecting the adoption of the inter-association guidelines.

The foundational approach for independent medical care is to assume an "athlete-centered care" approach, which is similar to the more general "patient-centered care," or delivery of

health care services focused on the individual patient's needs and concerns (Courson et al.,

2014). The following 10 guiding principles, listed in the Inter-Association Consensus Statement

on Best Practices for Sports Medicine Management for Secondary Schools and Colleges provide

an example of policies that can be adopted that help to assure independent, objective medical

care for college student-athletes. Although it appears that University of Maryland has integrated

the principles identified in the consensus statement, it is failure of #3 and #6 and that is of primary concern in the circumstances related to this event. Although this could be considered an atypical presentation of heat-related illness, there was no specific assessment that was completed to

rule out concern of this condition knowing the factors surrounding this specific case.

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1.

The physical and psychosocial welfare of the individual student-athlete should always be

the highest priority of the athletic trainer and the team physician.

2.

Any program that delivers athletic training services to student-athletes should always

have a designated medical director.

3.

Sports medicine physicians and athletic trainers should always practice in a manner that

integrates the best current research evidence within the preferences and values of each

student-athlete.

4.

The clinical responsibilities of an athletic trainer should always be performed in a manner

that is consistent with the written or verbal instructions of a physician or standing orders

and clinical management protocols that have been approved by a program's designated

medical director.

5.

Decisions that affect the current or future health status of a student-athlete who has an

injury or illness should only be made by a properly credentialed health professional (e.g.,

a physician or an athletic trainer who has a physician's authorization to make the decision).

6.

In every case that a physician has granted an athletic trainer the discretion to make decisions relating to an individual student-athlete's injury management or sports participation

status, all aspects of the care process and changes in the student-athlete's disposition

should be thoroughly documented.

7.

Coaches must not be allowed to impose demands that are inconsistent with guidelines

and recommendations established by sports medicine and athletic training professional

organizations.

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8.

An athletic trainer's role delineation and employment status should be determined

through a formal administrative role for a physician who provides medical direction.

9.

An athletic trainer's professional qualifications and performance evaluations must not be

primarily judged by administrative personnel who lack health care expertise, particularly

in the context of hiring, promotion and termination decisions.

10.

Member institutions should adopt an administrative structure for delivery of integrated

sports medicine and athletic training services to minimize the potential for any conflicts

of interest that could adversely affect the health and well-being of student-athletes.

Independent medical care legislation has been addressed by all three of the NCAA divi-

s10ns. In Division I Constitution 3.2.4.17 (independent medical care) became effective for the

Division I conferences with autonomy on August 1, 2016. In October 2016, all member schools

in the 27 non-autonomy Division I conferences opted in to the legislation. At its June 2016 meeting, the Committee on Competitive Safeguards and Medical Aspects of Sports (CSMAS) recommended sponsorship of similar independent medical care legislation to both Divisions II and

III and at the 2017 NCAA Convention, independent medical care legislation was passed, effect

August 2017, for Divisions II (Constitution 3.3.4.17) and III (Constitution 3.2.4.19). In August

2017, based on the CSMAS recommendations, the sitting Athletic Director proposed transitioning the athletics medical model of care from the athletics department to the University of Maryland Medical School in Baltimore. This proposed model was rejected by the President due to

insufficient justification to support the request.

The NCAA Sports Medicine Handbook provides a resource for sports medicine personnel

as a compendium of best practices. It is published in conjunction with the Competitive Safe-

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guards Committee within the NCAA. The handbook's Guideline lB provides a charge to athletics and institutional leadership to "create an administrative system where athletics healthcare

professionals (team physicians and athletic trainers) are able to make medical decisions with

only the best interests of student-athletes at the forefront (Parsons, 2015)." The Ch. 530 Annotated Code of Maryland, Article - Health Occupations SUBTITLE 5D. ATHLETIC TRAINERS

describes the following guidelines for licensed athletic trainers in the state of Maryland:

(C) AN EVALUATION AND TREATMENT PROTOCOL SHALL:

(1)

DESCRIBE THE QUALIFICATIONS OF THE LICENSED PHYSICIAN AND

LICENSED ATHLETIC TRAINER;

(2)

DESCRIBE THE SETTINGS WHERE THE ATHLETIC TRAINER MAY

PRACTICE;

(3)

DESCRIBE THE PHYSICIAN SUPERVISION MECHANISMS THAT THE

PHYSICIAN WILL USE TO GIVE DIRECTION TO THE ATHLETIC TRAINER; AND

(4)

SPECIFY THE TREATMENT PROCEDURES THE ATHLETIC TRAINER

MAY PERFORM (https://www.nata.org/sites/default/files/maryland-act.pdf).

Institutional line of medical authority should be established in the sole interest of studentathlete health and safety. An active member institution should establish an administrative structure that provides independent medical care and affirms the unchallengeable autonomous authority of primary athletics health care providers (team physicians and athletic trainers) to determine

medical management and return-to-play decisions related to student-athletes. In addition to an

administrative structure that assures such authority of primary athletics health care providers, an

active institution should designate a director of medical services to oversee the institution's ath-

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letic health care administration and delivery. At the University of Maryland, the Association

Athletic Director for Sports Performance oversees the Assistant Athletic Director for Athletic

Training who directly supervises the certified athletic training staff.

Though assumed to be mutual, autonomy and independent medical care are not synonymous. Autonomy in healthcare is considered a patient's right to decisions about medical care

without their health care provider trying to influence the decision. Patient autonomy does allow

for health care providers to educate the patient but does not allow the health care provider to

make the decision for the patient. The autonomy of the healthcare team providing services to

university student-athletes inherently carries a potential perceived conflict of interest due to the

dual responsibility of both providing care while being employees of the university.

The traditional model for providing athletic training services within collegiate athletics

has been the athletics model where the athletic trainer is hired by and supervised by an athletic

administrator within the athletics department. The primary goal is to establish a functional model for supervising, educating, and appropriately staffing certified athletic trainers and physical

therapists to provide high quality care to student-athletes. The plan should integrate concepts of

independent medical care in a functional model void of pressure and intervention of coaches and

administrators. These concepts should be integrated for all positions related to student-athlete

health and welfare.

There are multiple models of care currently available for athletic training services in the

collegiate setting. Courson and Goldenberg (Courson et al., 2014) discussed the following models:

Athletic Model (traditional model utilized in collegiate athletics).

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1. Athletic trainer employed by athletic department. The team physician is generally a contracted or fee-for-service non-athletic department person.

2. Athletic trainer and team physician employed by athletic department

Academic Model (a version of the athletic model where athletic trainers are employed in education settings and also provide athletic training services clinically).

3. Athletic trainer employed by educational program

Medical Model (The medical model has evolved at several institutions including the University

of North Carolina - Chapel Hill in 1973; The Citadel in 1988, and Vanderbilt University in 1990.

4. Athletic trainer and/or team physician employed by university health center or school

health services

5. Medical care contracted with outside hospital or private group

Each model offers pros and cons and it is essential that any University takes these into

consideration when determining which model is most appropriate to meet the needs of the environment. Academic and medical models are emerging as alternatives to the athletics model,

which is the more predominant model in the collegiate athletic training setting (Eason, Mazerolle, & Goodman, 2017). The medical model is proposed to support better alignment for both

patient care and the wellbeing of athletic trainers. Whereas the academic model has perceived

benefits, role incongruence exists, mostly because of the role complexity associated with balancing teaching, patient-care, and administrative duties.

Irrespective of model, it is imperative the college student-athlete has established medical

decision-making independence for appointed primary athletics healthcare providers (Wilkerson,

Hainline, Colston, & Denegar, 2014). The primary care sports medicine physician is trained in

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the medical conditions including but not limited to cardiac, heat illness, concussion, and other

conditions specific to the exercising athlete. The models, while difficult to design to meet the

needs of all institutions, do provide structure for providing independent medical care to studentathletes in a void of coaching and administrative influence. Many institutions are not willing to

relinquish control of athletic training services to outside entities, while others seek to offload the

financial burden. Others may see the value of such a partnership, and seek an alternative model.

Current Athletic Model

The current model embraced at the University of Maryland Athletic Department is primarily model one, but has aspects of the medical model as the athletic trainers are part of the athletic department but medical supervision is provided by physicians. This model is very prevalent

among intercollegiate sports at all levels of participation. The medical model is proposed to support better alignment for both patient care and the wellbeing of athletic trainers.

In an effort to ensure consistency in institutional services provided within the Big 10

Conference, The Big 10 Institutional Control document was drafted in 2016 (see document in

Appendix H), and updated in 2017. As outlined in this document, the University of Maryland

has a physician-directed health care model that employs licensed athletic trainers providing services to all varsity sport teams and their student-athletes. All physicians who supervise the athletic trainers are employed outside the Athletic Department. The Head Team Physician/Medical

Director reports to the UMOA Director of the Program in Sports Medicine, and also has a dotted

line reporting relationship to the University of Maryland Associate Athletic Director of Sports

Performance. He/ she is responsible to the University of Maryland Medical System in all matters

regarding his/ her clinical medical responsibilities. The ultimate authority for hiring University

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of Maryland athletic trainers and physical therapists employed by athletics appropriately resides

with the Assoc!ate Athletics Director for Sports Performance who also provides leadership and

administrative oversight for student-athlete health and welfare services. TheAssistantAthletics

Director for Athletic Training reports to the Associate Athletic Director for Sports Performance.

The Head Team Physician serves as the Medical Director and is a faculty member at the University Medical Center and is not an athletics department employee. Coaches do not have direct responsibility for the hiring or supervision of any member of the sports medicine staff, although a

coach may be consulted about the performance of the athletic trainer assigned to his or her team.

This line of organization meets the recommendation for removing conflict of interest. Only

Maryland sports medicine staff members are empowered to manage the treatment of student-athletes and to determine whether an ill or injured student-athlete is ready to return to play, including concussions. Per the EAP, in the absence of sports medicine personnel, coaches with training

in first aid, CPR and AED use may initially attend to an injured or ill student-athlete. Sports

medicine staff members will report any conflicts or concerns about the implementation of or adherence to institutional policies, procedures, and/or protocols for an ill or injured student-athlete

to the Associate Athletic Director for Sports Performance and the Head Team Physician to prevent any attempts to inappropriately influence the medical treatment of a student-athlete.

Proposed Medical Model

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Organizational Structure

Organizational charts and job descriptions were reviewed for all positions providing care

within this event. The Associate Athletic Director for Sport Performance provides oversight for

all athletic training staff and strength and conditioning coaches except for the Assistant Athletic

Director - Director of Football Performance. Administratively, there is a lack of efficiency in

roles and responsibilities between the Associate Athletic Director for Sports Performance and the

Assistant Athletic Director for Athletic Training. This is of concern as it is essential that a successful team include harmonized practices and clear communication within departments in order

to be effective and efficient. The Maryland reporting structure follows a traditional athletic training care model where certified athletic trainers directly report to administrators. There are no

athletic trainers directly reporting to coaches which is appropriate to decrease conflict of interest.

The current strength coach for football (Assistant Athletic Director - Director of Football Performance) does report to the head football coach. Clarity and departmental consistency needs to

be established for all organizational charts and job descriptions. The current review revealed

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multiple organization charts, many inconsistent with current models within the department. Current charts include a departmental organization chart (ICA Staff Org Chart_August 2018.pdf)

(Appendix L) and a chart with the proposed medical model (Appendix M) Clinical Sports Medicine Organizational Chart FYI 8), though it is not in effect. The primary concern in the current

medical model is the lack of clarity for ownership of the positions (athletics) and supervision

(medical model) with the UMB. It is not mandatory for athletic training services to be transitioned to UMB. This decision should be based on an evaluation of the health care services provided within the current model.

Associate Athletic Director for Performance Science

The Associate Athletic Director for Performance Science, who is also the designated

health care administrator, supervises the following; the Director of Sports Nutrition, the Director

of Basketball Performance (Assistant Director of Basketball Performance), the Director of

Strength and Conditioning - Olympic Sports (supervises five assistant coaches), the Assistant

Athletic Director of Athletic Training (supervising seventeen athletic trainers), the Director of

Clinical and Sports Psychology as well as eleven contracted team physicians, two Chiropractors,

one medical assistant, and one Physical Therapist (Appendix N). The position is administrative

in nature. The person in this position is educated as athletic trainer, but has relinquished their

credential. The Associate Athletic Director for Performance Science has a monthly meeting with

all direct reports. This structure is appropriately aligned to meet industry standard and the needs

of the department.

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Assistant Athletic Director for Athletic Training

The Assistant Athletic Director for Athletic Training supervises seventeen certified athletic trainers that provide care to the University of Maryland student-athletes. This position is responsible for the day-to-day organization, administration, and clinical application of comprehensive health care services to over 500 student-athletes. The Assistant Athletic Director for Athletic

Training assists with the sports medicine / athletic training operations of all teams, attends practices and events, and maintains daily communication with coaching staffs, strength and conditioning personnel, physicians, and athletic administrators.

This structure is appropriately aligned to meet industry standard and the needs of the department. This position maintains direct oversight of operations within the athletics trainers and

coordinates all services provided.

Certified Athletic Trainers

There are currently 17 certified athletic trainers working in the Athletics Department. All

17 are currently certified in an appropriate level of CPR andAED. All Certified Athletic trainers

are currently licensed within the state of Maryland as Certified Athletic Trainers. The Head

Football Athletic Trainer is dual credentialed as a certified athletic trainer and physical therapist.

A complete organization chart is available Appendix 0.

All certified athletic trainers are ultimately supervised by the Assistant Athletic Director

for Athletic Training who is supervised by the Associate Athletic Director for Sports Performance. This structure is appropriately aligned to meet industry standard and the needs of the department.

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Strength and Conditioning Staff

The Assistant Athletic Director - Director of Football Performance directly reports to the

head football coach and is not aligned to the Associate Athletic Director for Sports Performance.

The Assistant Athletic Director - Director of Football Performance has a staff of four Assistant

Strength Coaches and one nutrition position supervised as they work only with football. A complete organization chart for strength and conditioning is available as Appendix P. The Sports Nutritionist for Football is supervised by the Assistant Athletic Director - Director of Football Performance as presented in Appendix P and does not report to the Associate Athletic Director for

Sport Performance.

Team Physicians

The Head Team Physician (primary care sports medicine) is housed under the Department of Orthopedics executive director. There is an interim director, Program in Sports Medicine within the Department of Orthopedics supervising the Head Team Physician. The four primary care sports medicine physicians are housed in Family and Community Medicine under the

Department of Orthopedics at the University of Maryland (UMB). An organizational chart is

presented as Appendix Q (UMB Ortho Sports Medicine Org Chart). This chart presents the current Head Team Physician from the medical school providing contracted services with the University of Maryland Athletics Department. The Team Physicians include primarily patient care

though they explained the University of Maryland athletic training procedures are written and

compiled by the Assistant Athletic Director for Athletic Training with input from staff. The

physicians expressed they were involved with the general medical procedures (diagnostic ultra-

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sound, general labs, etc.) and track them in the clinics provided for student-athletes in Athletic

Training Rooms though these on-campus procedures are not filed for insurance reimbursement.

New Employee Onboarding

The education of new staff is always a challenge regarding specific procedures, treatment

plans, and general orientation to company procedures. It is recommended a plan be developed

for all new employee for appropriate integration to departmental specific procedures. It is important that compliance is accomplished and identified by the appropriate oversight manager.

This Onboarding process is vital to strength of staff and providing quality care to patients.

Credential Monitoring

Non-Staff Credential Monitoring. There was no evidence of any screening or monitoring

of non-university personnel providing care to student-athletes relative to credentials, continuing

education or liability/malpractice insurance. While not a major focus of this report, the observation is noted.

Staff Credential Monitoring. All Strength and Conditioning staff were current with professional certification on May 29, 2018. Likewise, all Athletic Trainers had valid state of Maryland licenses within their practice domains on May 29, 2018. All members of both groups had

current cardiopulmonary resuscitation on May 29, 2018. Details are presented in Appendix R.

Nutritional Supplements

During interviews with athletic trainers and strength coaches, questions were addressed to

determine if nutritional supplements are monitored and regulated by the institution. To the person, it was intimated that nutritional supplements while not prevalent within the program, are

truly monitored for nutritional compliance by the nutritionist and the certified athletic trainers. If

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nutritional supplements were indicated, they would be purchased by the athletic trainers and/or

nutritionists.

Staff Education

The staff education sessions over the past year are presented below in Table 2. No specific meeting notes were provided nor was an attendance list of participants. The Assistant Athletic

Director for Athletic Training did describe routine meetings with his staff to address education.

Various work groups have been created by the Assistant Athletic Director for Athletic Training

for areas such as EAP Workgroup and documentation workgroup. The Assistant Athletic Director for Athletic Training coordinates policies and procedures and refers to this as Team Clinical

Management Procedures. There is no verification that team physicians review procedures.

Table 2. Athletic Training Staff Education

Topic

Date

July 9, 2015

November 20, 2017

Staff Orientation / Staff Training

EAP Working Group

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Table 2. Athletic Training Staff Education

June 18, 2018

EAP Working Group

All training and educational sessions should be coordinated with the Head Team Physician regarding content of training, best practices, and monitoring for compliance. The example of training within the hospital or medical model should be used as a template.

Record Keeping

All football athletic injuries are required to be entered into the Presagia electronic medical record system. It was outside of the scope of this project to validate the compliance of medical record entry for the department. However, it was communicated that the Head Football Athletic Trainer identifies injuries and appropriate information to be entered into Presagia, that are

subsequently entered by one of the assistant athletic trainers. A department-wide medical record

keeping review and audit was not completed for this report.

The use of an electronic medical record system and entry of all reported injuries is expected to meet industry standard and health care provider legal requirements.

On-Campus Medical Clinics

There are daily clinics at University of Maryland Athletic Training Rooms staffed by the

Head Team Physician and Team Physicians (Primary Care Sports Medicine) and also Team

Physicians (Orthopaedics). A schedule is planned by the Assistant Athletic Director for Athletic

Training and coordinated with the Head Team Physician. The final schedule is shared with all

team physicians and athletic trainers via cloud calendars. Clinics are scheduled in both the Gos-

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set Team House and Xfinity Center. There are 17 hours of clinics by Primary Care/Sports Medicine physicians; 4 hours of orthopedic clinics; and four hours for chiropractic care.

This amount of physician availability meets standards within Power 5 conferences.

Athletic Medicine Review Board

The Athletic Medicine Review Board is a concept that has been implemented at several institutions to involve best medical practices with oversight from non-institutional professionals from a

variety of specialties (cardiology, orthopaedic surgery, neurosurgery, psychiatry, emergency medicine, athletic training, physical therapy, strength and conditioning, nutrition, etc.). It seems prudent to integrate these concepts into the policy development and annual review of procedures of

sports medicine.

Observations

1. Lightning monitoring for the University of Maryland non-football sports is based off of the

radar at Maryland Stadium though other venues are one to two miles away.

2. Interviews with the Assistant Strength Coaches revealed unfamiliarity with EAPs and AED

location specific to the weight room.

3. No AED is located within the weight room, but is accessible in the hall roughly 30 feet from

the weight room.

4. No cold water tub was setup for the activity and not utilized though several were located in

proximity to the event and athletic training room.

5. The trauma bag utilized for football conditioning run had to be retrieved to the Gosset Athletic Training Room for treatment of Jordan McNair.

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6. There was apparent confusion as to where personnel should meet EMS upon their arrival

(field level or front parking lot of Gosset Team House).

7. Staff personnel were not sent or directed to meet EMS at the appropriate pre-determined location that is indicated on the Maryland Stadium EAP.

8. Weather monitoring was from a contracted service (WeatherOps) based upon telephone conversation with University of Maryland facilities office. The data is reported as not site specific as the data feed utilizes multiple National Weather Site data points from within the geographical area. A historical record was obtained from https://www.wunderground.com/history/daily/us/md/college-park/KCGS/date/2018-5-29 and reveals the temperature as 81AdegF at

both 5: 17 and 5:37 pm. The facility office contact also informed the lighting identification

for all University of Maryland feeds is based off the radar detection at Maryland Stadium.

The wet bulb globe temperature was not obtained by the Sports Medicine Staff prior to or

during the workout.

5:17PM

9. Cold water immersion was available in the Gosset Athletic Training Room but it was not utilized.

12. The student-athlete, once symptomatic, admits to staff Athletic Trainers that he did not eat

prior to the workout and that he had only eaten a bowl of cereal in the morning.

13. The student-athlete's rectal temperature was not established nor monitored.

14. The student-athlete's vital signs were not established nor monitored. No vital signs were assessed or recorded in any of the records nor the Presaggia incident report.

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15. Immediate and aggressive cooling of the student-athlete did not occur. Ice packs and ice towels were utilized.

16. There is no reported record of individual fitness assessment by the strength staff prior to initiation of this test. The test of May 29, 2018 followed a four-week break, though student-athletes were encouraged and reminded to maintain individual workouts over the break. The

conditioning session started at 4: 15 pm.

17. The conditioning test of May 29, 2018 was the initial day back from a four week off-time.

Acclimatization is a concern as this is the initial activity of the summer. The conditioning activity and test was not long in duration.

18. The student-athlete's pre-participation examination was most recently conducted on April 16,

2018. There was a followup consultation with the Head Team Physician on May 7, 2018

with "greater than 50% of this visit was spent on patient education and counseling low vitamin D, sources of vitamin D and recommendations for repletion".

19. All current strength staff are certified by a national accreditation agency as strength coaches.

20. All current strength coaches are currently certified in cardio-pulmonary resuscitation.

21. All current certified athletic trainers are certified in cardio-pulmonary resuscitation.

22. All current certified athletic trainers are licensed within the state of Maryland. One member

is dual credentialed and also licensed as a Physical Therapist.

23.

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24. The Head Team Physician was not actively involved in education and training of staff to invoke best practices in all aspects of the work of athletic trainers utilized for care ofUMD

student-athletes.

25. All Football Strength Coaches are responsible to the Assistant Athletic Director - Director of

Football Performance, and not the Associate Athletic Director for Sports Performance.

26. Hydration testing (urine specific gravity) is being conducted by members of the football

strength and conditioning staff; none of which has undergone specific training for urine specific gravity testing. Tests are classified as red, yellow or green. Those in the red area are

not allowed to participate in practice until hydration improves.

27. Hydration test results are provided to the Dietician for development of a "hydration recommendation" which is shared with athletic trainers and position coaches, as well as recommendations for hydration being posted on student-athlete lockers. To emphasize hydration, a

gallon of water was provided to each student-athlete by the Strength and Conditioning staff

to be consumed prior to workouts. After the events of May 29, 2018, Jordan McNair's unopened gallon of water was found in his locker.

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28. Information reported to UMD attorney, athletic director, and senior administration two days

post event was not representative of activity and care on the field May 29, 2018. Review of

videos confirmed UMD administration's concerns.

29. When meeting with the Head Team Physician on August 2, 2018, she did express her concern

due to the reported delays that occurred on May 29, 2018 in the care of Jordan McNa