As an athletic trainer in a high school environment, I believe providing cardiac information to students, parents, coaches, and others is a great start.  Proper cardiac screening of student-athletes is also important for the Virginia Board of Education to solidify in their Guidelines for Policies on Sudden Cardiac Arrest Prevention in Student-Athletes.  Prevention ranks first among the best practices regarding cardiac health.  However, as many as 80% of patients with Sudden Cardiac Deaths (SCD) are asymptomatic until sudden cardiac arrest occurs, suggesting that screening by history and physical examination alone may have limited sensitivity to identify athletes with at-risk conditions (National Athletic Trainers' Association Position Statement: Preventing Sudden Death in Sports. Journal of Athletic Training 2012:47(1):96-118). Therefore, preparations beyond information and screenings are warranted to meet the goals of returning student-athletes back to school and perhaps athletics.  In this case, prevention shifts to mitigating the harm of cardiac arrest by taking measures to prevent death.  This is best accomplished through 1) early recognition of the cardiac incident, 2) calling emergency services, 3) promptly starting Cardiopulmonary Resuscitation (CPR) while awaiting arrival of the Automated External Defibrillator (AED) and emergency medical services, 4) applying the AED within two minutes of the victim’s collapse, and 5) turning the care over to emergency medical services for advance care and transport to the closest cardiac care facility.

Therefore, my recommendations include:

1. Every coach should maintain CPR certification while employed or as a volunteer for a K-12 athletic team,
2. Require schools to ensure AEDs are on-site, maintained and readily available to each athletic venue within two minutes.
3. Require K-12 schools to have in place and review venue specific emergency action plans (EAP) among the members who would be responsible for implementing the plan.
4. Require schools to create a cardiac emergency response team and practice in-school and after-school cardiac arrest drills three times a year.

To elaborate, members of the coaching staff should be required to obtain and maintain CPR certification.  Currently, this is neither a requirement of our Commonwealth, nor Virginia High School League (VHSL).   Although Virginia Department of Education (VDOE) has mandates for teachers, counselors and administrators to obtain CPR and first aid training for initial licensure and renewal (https://doe.virginia.gov/teaching/licensure/emergency_first_aid_cpr_aed/index.shtml), that VDOE requirement does not extend to coaches who supervise the same students during school sponsored athletic programs where the risk of cardiac arrest may be increased.  Furthermore, the VHSL's current guideline states that a coach needs to obtain a CPR training within three years of becoming a coach and the training does not need to be repeated.  In other words, a coach with 30 years of experience must receive CPR training once.  Although I personally believe that the VDOE CPR policy for licensed educators have moved away from its original intentions of having more staff trained to handle a cardiac emergency, the recent move to license educators every 10 years means that a teacher with the same 30 years of experience would be certified a minimum of three times.  Furthermore, VDOE's current guidelines for teachers require a hands-on component to their CPR education that coaches are not required to complete. Interestingly, football coaches would never have a student-athlete watch a video on proper football tackling techniques and assume that they know how to tackle the opposing ball-carrier on game day.  Yet, the VHSL suggests through their policy, that watching a video will suffice for adequate training to prepare a coach to act appropriately when a student-athlete collapses of cardiac arrest.  Therefore, I strongly believe that ALL coaches of K-12 student-athletes should maintain current CPR certification from a nationally recognized organization that includes hands-on skill demonstration.

Training for AEDs debuted in the year 2000.  Since then, AEDs have become a standard of care for individuals in cardiac arrest by optimizing the victim’s chance of survival.  In fact, every minute an AED is delayed, the patient’s chance of survival decreases by 10 percent.  Despite AEDs being a standard of care and its training mandated for VDOE licensed educators, there are no mandates that require Virginia schools to have AEDs.  This NEEDS to change.  If the VDOE is serious about providing the best guidelines to save individuals from cardiac arrest, then all schools should have one or more on-site AEDs that are positioned to reach every aspect of the school, including athletic fields within two minutes of the onset of the cardiac arrest.  Virginia law (Code of Virginia § 8.01-225) established liability protections to CPR and AED instructors, establishments that own and maintain AEDs, and responders that operates an AED during an emergency.  It is time that schools across our Commonwealth be required to have on-site AEDs.  It is possible that all Virginia schools to currently have an AED within two minutes of all locations of their campus and, in that case, this suggestion may be overlooked.  On the other hand, years ago I had a conversation with a superintendent of a Virginia public school district that had two schools without on-site AEDs.  At the end of our conversation, this superintendent would not purchase AEDs for those schools because Virginia law did not require it.  If this superintendent was perfectly fine not having AEDs in all the schools in their district, perhaps other superintendents are too.

Venue specific Emergency Action Plans (EAPs) are required by the VHSL, however there is no official governing body that oversees athletic teams below the high school level.  Therefore, it is imperative that all of Virginia’s K-12 schools be required to have EAPs that are specific and encompasses all athletic venues.  Furthermore, all venue specific EAPs should be reviewed annually by the individuals responsible for implementing the EAP.  Reviews are important to discuss and delineate individual roles and responsibilities of each aspect of the plan.  When an emergency arises, it would take precious time away from the ill/injured individual to provide directions and delegate responsibilities to others.  Not knowing how to put an EAP into practice is just as bad as not having one.  That is why I believe all K-12 schools should have EAPs in place and review the plan among the members who would be responsible for implementing it, including coaches, school/athletic administrators, and emergency personal.

The threat of cardiac arrest is real.  As a matter of fact, the law and guidelines that require licensed educators and high school graduates to be trained in CPR, AEDs and first aid, originated out of a cardiac arrest at a Virginia middle school.  In that situation and many others similar to it, the call for help was not enough to optimize the victim’s chance of survival.  Additionally, I know that being tested on high fidelity manikins and putting your CPR and AED skills into practice to become certified is helpful in validating current skills, but it, too, is not enough to ensure one’s skills as time passes.  It is continual practice that enhances one’s ability to be consistent in delivering high quality CPR.  Additionally, practicing CPR/AED skills in realistic scenarios are proven helpful to responsibly and reasonably act during a real event.  This is the goal of cardiac drills.  If the Commonwealth of Virginia can require fire drills, earthquake drills, lockdown drills, tornado drills, then the Commonwealth should certainly require CPR/AED drills throughout the school year both during and after school.  Consider the situation involving Claire Crawford, her school elected to be affiliated with Project Adam, a national movement to get schools prepared for cardiac events.  Claire and her family attribute her rejuvenated life to the school’s cardiac care team and routine cardiac drills that they practice.  More of her detailed story can be found on this YouTube video https://www.youtube.com/watch?v=yg3Ry_DzJgI.

As echoed in Stop the Bleed campaigns, when seconds count help is only minutes away.  This rings true throughout many emergency situations; relying only on the arrival of others to initiate lifesaving care, is a waste of valuable time as it decreases the victim’s chance of survival. I believe instilling my four recommendations 1) every coach maintain CPR certification while employed or a volunteer for a K-12 athletic team, 2) require schools to have AEDs on their property and ensure on-site AEDs are maintained and readily available to reach the victim of cardiac arrest within two minutes, 3) require K-12 schools to have and annually review emergency action plans, and 4) require schools to create a cardiac emergency response team and practice cardiac arrest drills throughout the year, will ensure that the victim of cardiac arrest has the best chance for survival.

I am honored to be able to voice my opinion on this forum.  It is my hope that you find my recommendations helpful.  My passion about CPR and emergency response extends from my work as a CPR, AED, and first aid instructor, athletic trainer, and EMS provider. Throughout all of my experiences, I know the feeling one has when CPR/AED revives an individual and unfortunately, when it doesn’t.  Some of the 1,200+ people that I taught in CPR and emergency response know these feelings as well.

Lastly, I am willing to answer any questions you may have about my recommendations, and/or provide more clarifications of my statements.  Additionally, please know that I am willing to assist the VDOE in the creation of the final Guidelines for Policies on Sudden Cardiac Arrest Prevention in Student-Athletes.

Respectfully,

K. Ashley