It’s in the Bag: A Practical Guide to the Team Physician’s Medical Supplies While on the Road
Authors: Chris McGrew, MD, Ann Gateley, MD, and Robert Schenck, Jr., MD, Department of Orthopaedics and Rehabilitation, Division of Sports Medicine, University of New Mexico School of Medicine, Team Physicians, University of New Mexico Lobos, Albuquerque, NM.
Editor’s Note—The role of the team physician involves a myriad of responsibilities and opportunities in the care of the athlete. One very interesting area involves traveling with various athletic teams for the road game, tournament, or bowl appearance. These trips vary in length away from home and might include relatively short 1- to 2-day excursions for regular season athletic contests vs extended trips for tournaments and bowl games. The team physician plays a vital role in working with the certified athletic trainer in coordinating care for not only the athletes but also the care for coaching and other support staff while the team is "on the road."
Traveling with a team can present considerable challenges, and while colleagues and friends may think you are on a weekend holiday or extended vacation with incredible glamour, in reality the situation may be very different. Traveling with a team often involves working in less than ideal conditions with a variety of personalities who are dealing with the stresses and demands of competition and travel. Road trips can involve extended periods of time away from the physician’s family and medical practice, which often adds to the practicioner’s own stress. From a medical standpoint, a successful road trip depends on a combination of careful preparation and the ability to adapt to changing circumstances. A good attitude and the ability to improvise are also essential for the team physician. Although experience does play a tremendous role in the physician’s comfort level with medical issues on the road, the need to be prepared plays an important role as well. To optimize the physician’s ability to perform well on the road, a carefully prepared travel medical bag is essential. Having the appropriate supplies and equipment will save time that otherwise would have been spent waiting in local facilities (which may not share the athletic team’s sense of urgency) for medical and surgical care as well as the potential for significant cost to obtain prescriptions. The contents of such a medical bag will vary depending on the makeup of the medical support team, the sport being covered, the time of year, the size of the travel party, and the destination and local facilities available; nonetheless, for the purposes of this monograph we will focus on the needs of the college team physician traveling within the United States.
The Bag Itself
Many options are available for the travel medical bag and will reflect personal preferences. We have preferred a "soft" bag of durable, weatherproof material that can be easily carried onto a bus or airplane (see Figure 1 below). It should have a variety of pockets and compartments to organize prescription and over-the-counter (OTC) drugs efficiently. The exterior should be distinct from the standard team gear for easy identification. Obviously any travel bag can be stolen and broken into; however, it seems prudent to have at least a minimally secure section of the bag for prescription drugs. A simple small diameter cable lock is useful for running through the zippers of a particular compartment.
An inventory of the medicines and supplies carried in the bag is essential for regular updates and revisions (see Table 1). As medications are dispensed, appropriate identification of the patient and prescription (documenting lot numbers and expiration dates) should be recorded. Encounter sheets/logs should be used to document each patient visit. Even a rudimentary note-taking system is useful, especially to aid in dictations. A compact "Dictaphone" is very useful for dictating notes concerning patient care, which can be transcribed when back home and added to the patient’s medical record. Programs for hand-held PDAs are also an option for records on the road and are becoming more popular as a way to carry a copy of the entire team’s medical record.
We have found that organization by common anatomical areas of complaint and typical illnesses is helpful for maintaining completeness. Other considerations include special needs of individual athletes and members of the traveling party. The bag should be checked regularly for out-of-date medications (as well as supplies) regularly, and we have found that an inventory list is most useful (see Table 1). The bag should not be left in extreme environments (eg, car trunks) where temperature extremes can cause damaging effects to medications. There are many options for references for medications including quite small paperback references such as the Sanford Guide to Antimicrobial Therapy (Antimicrobial Therapy, Hyde Park, Vt) and the Tarascon Pocket Pharmocopeaia (Tarascon Publishing, Loma Linda, Calif). Other options include software available for PDAs, eg, "ePocrates" (www.ePocrates.com).
Typical problems on the road include conjunctivitis and corneal abrasions. Conjunctivitis can be of many types (allergic, chemical, viral, bacterial, etc) and differentiation can be difficult. Frequent eye irrigation with normal saline drops and the use of warm compresses every few hours can relieve many symptoms. The urge to treat every conjunctival irritation with topical antibiotics should be resisted. Evaluation for a corneal abrasion can be attempted with the use of fluoscein strips and an ultraviolet light source, but a complete exam can only be done with the use of a slit lamp. One of the key issues concerns contact lens wearers; and team members should be reminded to bring their eyeglasses on the road because if problems arise, "the contacts must come out!"
What to Bring
- Saline drops;
- Topical allergy drops; and
- Topical ophthalmic antibiotic-ophthalmic bacitracin-polymixin B, erythromycin, or a fluoroquinolone are all acceptable as first-line choices.
Cerumen impaction, external otitis, and otitis media top the list for isolated ear problems on the road. Cerumen removal can be facilitated with a softening agent such as colace and irrigation with a soft rubber bulb syringe and warm saline. External otitis is best treated with a topical agent such as cortisporin gentamyicin otic suspension. (Classic findings include an erythematous external canal with or without debris along with pain with tugging on the ear lobe.) In addition to external otitis, middle ear infections can also be extremely debilitating while on a road trip, especially with air travel. Decongestants, warm compresses, and analgesics are important to comfort. In most cases the first-line for the treatment of adults with acute otitis media will be amoxicillin.
What to Bring
- Polymixin B + Neomycin + Hydrocortisone combination (cortisporin otic suspension);
- Docusate Sodium (Colace®) drops; and
- Soft rubber bulb syringe.
Nasal complaints can be quite annoying while traveling and congestion can contribute to discomfort while flying. Twice daily nasal saline irrigation with a rubber bulb syringe and a homemade (hotel-made!) solution of ½ teaspoon table salt in 8 ounces of warm water is a good start for most patients with nasal congestion. For the athlete who is being bothered by dry nasal mucosal tissues, OTC saline sprays can be useful. The use of oxymetazalone nasal spray can be of great help for the temporary relief of nasal congestion with a rapid onset, reasonably long duration (10-12 hours), and a lack of systemic effects (doesn’t disrupt sleep). A key point to remember with the use of this product is to limit it to a 3-day total at any given time to avoid problems with rebound congestion and rhinitis medicamentosa. Topical corticosteroids have become the gold standard for the treament of allergic rhinitis and once-a-day agents are available. The onset of action can be delayed, however, and oral meds (antihistamines, decongestants) may need to be used as the topical agents are being initiated. The efficacy of any of the topical agents is enhanced if the nasal passages are cleaned out with saline irrigation first.
What to Bring
- Oxymetazalone hydrochloride nasal spray;
- Nasal saline (can make your own—½ teaspoon salt to 8 oz warm water); and
- Fluticasone proprionate (Flonase®).
With travel, athletes often complain of scratchy throats, especially with air travel and changes of climate. Without fever or other systemic signs or symptoms, most of these worries can be treated with increased oral fluids, frequent salt water gargles, OTC throat lozenges, and reassurance. If a pharygitis is suspected other issues should be considered. Most cases of pharygitis are viral in nature and will resolve with simple forms of intervention. The above recommendations along with the use of acetaminophen and or ibuprofen is usually sufficient for the sore throat without evidence of pharyngitis. We have found that in some cases the use of zinc gluconate lozenges within the first 24 hours after the onset of symptoms can be helpful for reducing the intensity and duration of the sore throat. Such lozenges are readily accepted and tolerated by the athlete, in our experience. The team doctor should be alert to the possibility of strep pharyngitis (occasionally coming in epidemics within a team). The antibiotic of choice is penicillin, but an alternative such as erythromycin should be available for those that are pen allergic. It should be remembered that the treatment of strep pharyngitis is primary for rheumatic fever prophylaxis. Changing the course of the acute illness is questionable at best with the use of antibiotics—if an effect is to be had, antibiotics probably have to be started within 24 hours of the onset of symptoms. One last point about antibiotics: antibiotic therapy is frequently requested by athletes, coaching staff, and support staff. Proper use of antibiotic therapy is recommended and should be based on clinical findings.
What to Bring
- OTC throat lozenges (Cepastat®);
- Salt water gargles (1 teaspoon table salt to 8 oz warm water);
- Zinc Gluconate throat lozenges (Cold-Eeze®); and
- Antibiotic of choice for strep pharyngitis: Pen VK 500 b.i.d. for 10 days; alternative erythromycin 250 q.i.d. for 10 days—number of doses depends upon the size of team and length of trip.
Upper respiratory infections (URIs) account for most of the nonorthopaedic training room visits at most colleges and certainly provide a good amount of business for the team doctor on a road trip. The large majority of URIs are viral in nature and only require symptomatic and supportive care. Antibiotics may occasionally be required for some conditions, but the temptation to overtreat URIs with antibiotics should be resisted. Amoxicillin is still the first-line antibiotic to treat most cases of sinusitis. Azithromycin has advantages for bronchitis with its simple 5-day dosing schedule. The proper use of antibiotics is recommended, but in our experience, there may be some dissatisfaction when an antibiotic is not prescribed, despite the clinical evidence pointing to a viral URI.
Many of the problematic symptom areas associated with URIs have been discussed above. For nasal congestion, pseudoephedrine, saline nasal washes, and oxymetazolone HCL nasal spray can be helpful. For the athlete with rhinonnorhea and postnasal drainage, an addition of an antihistamine may be useful, especially at bedtime to assist with sleep. Some athletes may find good relief with a combination antihistamine/decongestant such as chlorepheramine/ pseudoephedrine HCL. Many times athletes are particularly bothered by a cough. It must be remembered that the best treatment for cough is hydration—water is the most effective expectorant. Additional relief may be obtained from OTC products containing dextromethorpan. Another option that may be useful is benzonatate.
For nighttime cough that is disrupting sleep, codeine can be very effective. A reminder about reactive airways associated with URIs—the athlete may benefit from short-term use of inhaled beta 2 agonist such as albuterol, especially prior to exercise.
What to Bring
- Oxymetazolone nasal spray;
- Benzonatate (Tessalon Perles®);
- Cough medicine with dextromethorpan;
- Cough medicine with codeine;
- Amoxicillin (Amoxil®); and
- Axzithromycin (Z-Pack®).
Probably only second to the URI as the most common clinical sports medicine complaint is gastroenteritis. Most forms of gastroenteritis are caused by viruses such as Rotavirus and Norwalk agent and are usually self limited for a total of 2-3 days. Bad enough at home, such clinical scenarios on a road trip can seem like an eternity for the athlete and a nightmare of recurrent visits for the team physician. If there is no evidence of fever or hematochesia, then it is probably reasonable to use antimotility agents such as loperamide or diphenoxylate HCL with atropine, although this may prolong carrier state of some organisms. Pepto-Bismol can be helpful for both nausea and diarrhea and is an important adjunct to have available. Almost all cases can be treated with oral rehydration; however, on the road IV rehydration will almost certainly make the athlete feel better sooner and may allow for participation in a contest at least on a limited basis.
What to Bring
- Loperamide (Immodium®);
- Diphenoxylate hydrochloride with atropine (Lomotil®);
- Prochlorperazine (Compazine®)—p.o., suppositories, and injectable; and
- Intravenous fluids, IV starter kits, sharps disposal kits and contamination material bags (usually brought with training room equipment separate from the medical bag due to bulk and weight).
This problem is very common on road trips with the change in diet and added stress from competition. OTC antacids, H-2 blockers and proton pump inhibitors are all quite useful for quieting down symptoms. As always patient education and reassurance can go a long way in helping athletes deal with these annoying symptoms on road trips.
What to Bring
- OTC antacid;
- Cimetidine® (800 mg b.i.d.); and
- Esomeprazole magnesium (20 or 40 mg q.d.).
If you are going to give medicines on the road (especially injectable medications), it is imperative to have the ability to initiate treatment for an anaphylactic reaction. Epinephrine and antihistamines are the mainstays of initial treatment and come in easy-to-use, prepackaged, anaphylactic kits. For general allergic reactions (not anaphylaxis) oral prednisone and/or injectable corticosteroids can be very useful if oral antihistamines are not effective.
What to Bring
- Benadryl® p.o.;
- Prednisone® p.o.; and
- Celestone® or Kenalog® injectable.
Pain is a constant issue in dealing with sports teams and being on the road is no different. Minimizing controlled substances that have to be carried on the road is a good idea and we have been able to travel effectively with only acetaminophen with codeine as our sole narcotic with the addition of other analgesics. We have also found that injectable ketorolace tromethamine (Toradol®) is quite helpful in dealing with acute pain situations, especially when we are traveling home immediately after the contest. The stress associated with travel can trigger acute migraine episodes and isometheptene mucate, dichloralphenazone with acetaminophen (Midrin®) are effective first-line agents. The availability of COX-2 NSAIDs has a useful place in managing pain, especially in an attempt to minimize side effects.
What to Bring
- Ibuprofen, 800 mg;
- Indocin, 25mg—for the booster with gout;
- COX-2 NSAIDs such as Bextra®, Vioxx®, or Celebrex®;
- Ketorolac tromethamine (Toradol®)—injectable;
- Isometheptene mucate, dichloralphenazone with acetaminophen (Midrin®) (migraines—2 at onset then 1 q.h. until headache is gone; no more than 5 in 12 hours);
- Sumitriptan succinate (Immitrex®) (if you have an athlete with known migraines and has used it before); and
- Acetaminophen with codeine.
Remember that albuterol is the most important asthma medicine to have available because of its role as a "rescue drug" in the setting of an acute asthma attack. Spacers are also extremely helpful. Many athletes have poor technique to begin with in using inhalers and in the setting of stressful road travel, especially on the sidelines of a contest, spacers are invaluable. Watching the athlete use the inhaler properly is extremely important in the effectiveness of the drug.
What to Bring
- Salmeterol xinafoate (Serevent®);
- Fluticasone (Flovent®); and
Nasal corticosteroids are now the gold standard for treatment of allergic rhinitis; however, onset of action can lag for several days. Oral antihistamines are more likely to give immediate if not complete relief and it is a good idea to have regular and nonsedating forms. Nasal saline washes are very helpful as well as nasal spray decongestants for short-term use, as noted above. Topical allergy eye drops may also be useful for same day relief of eye symptoms. See above for additional information on eye and nasal symptoms.
What to Bring
- Diphenhydramine (Benadryl®);
- Combination antihistamine/pseudoephedrine such as Actifed®;
- Nonsedating antihistamine such as Zyrtec® or Claritin®; and
- Flonase® (takes a few days to start working—give them some Zyrtec® or Claritin® and nasal saline washes to get started with).
Although usually not a big problem on road trips, dermatologic issues can be extremely irritating to the affected member of the traveling group. For ringworm, athlete’s foot, jock itch, etc, OTC antifungals such as Tinactin® are usually effective. Nonetheless, for those athletes not responding to OTCs, prescription medications such as Spectazole® are useful to have available. Generic topical dermatitis or pruritic skin rashes usually get some relief from OTC—Hydrocortisone Cream. For those with more severe symptoms, we suggest having oral antihistamines and Triamcinolone 0.1% Cream available. Outbreaks of Herpes Simplex type 1 skin conditions such as "cold sores" and "herpes gladiatorum" can be very upsetting to the athlete and may limit competition (especially wrestlers) Oral antivirals such as acyclovir can help speed resolution and reduce symptoms.
What to Bring
- OTC antifungal such as Lamisil AT®;
- Econazole Nitrate (Spectazole®);
- OTC 0.5 % Hydrocortisone cream;
- O.1 % Triamcinolone cream;
- Miscellaneous Conditions; and
- Insomnia—Vistaril® p.o. (rapid onset, short half-life-downside may feel drowsy, dry mouth).
Female UTI—Previous History—Trimethoprin Sulfa, Macrodantin, or Amoxicillin
Candida vaginitis—previous history of Vaginal Candidiasis and has no other medical issues—Diflucanä 150 mg p.o. one time
Canker Sores (Apthous Ulcers)—liquid benadryl applied with a cotton-tipped applicator to the sore is extremely useful and easy to apply. Other options include tetracycline solution (contents of 1 capsule of tetracycline emptied into 3 oz warm water and swished around the mouth for a minute and spat out; repeat 3 times per day after meals) also works well but the taste can be less than palatable.
Booster with Angina/ Chest pain—This is a true emergency and one should give the patient an adult strength aspirin to chew on and call 911. This is one of those road trip clinical scenarios that requires immediate transfer to a medical institution and should not be attempted to be worked up at the hotel or in the training room.
Deciding what equipment to carry on the road should be coordinated with the athletic training staff. Bulkier items (such as casting supplies, suture kits, and IV bags/IV setups) can usually be shipped with team equipment in large trunks. Taping and bracing supplies will also be organized by the athletic trainers
Diagnostic—The minimal supplies included in the medical bag are the following: stethoscope, blood pressure cuff, oto/opthalmoscope, (don’t forget the charger and/or extra batteries) thermometer, penlight, reflex hammer, gloves, swabs, tongue blades, and urine chemistry dip sticks.
Laceration care—Be sure to pack your preferred sutures (have multiple types and sizes available), syringes, irrigation equipment, needles, catheters, anesthesia (Lidocaine without epi, Lidocaine with epi, Marcaine), steri strips along with laceration repair adhesives (eg, Dermabond®) and a staple device (very helpful for scalp lacerations) are extremely important.
Miscellaneous—Paper bags for hyperventilation treatment, pocket mask for rescue breathing/CPR, Large bore angio cath for tension pneumothorax (14-16 gauge), bandage scissors, sharps container, and biohazard bag are also needed.
Carried in separate containers along with the main team equipment:
- IVs—10 set ups; 20 bags of fluid—normal saline and D5/NS;
- Casting Materials—appropriate fiberglass, stockinette, padding, and splinting materials;
- Laceration repair kits with appropriate drapes and instruments (2-3 kits are usually sufficient). Compact skin sterilization prep kits are also necessary.
Providing medical care out of the state where the physician is licensed is rarely questioned, but in our experience, the team physician is the most trusted and, for all intents and purposes, is the treating physician for the team. It is worth checking on this with your legal advisor and/or university athletic department counsel if there is any doubt as to what can be done within your scope of practice out of state. Certainly, issues for hospitalization for catastrophic issues should be coordinated with instate physicians, and although not routine, are usually handled by the home-team sports medicine physicians in conjunction with the visiting-team physician. It is our opinon that it is impractial or even impossible for any one team physician to provide for, or carry, the entire equipment/supplies for instituting ACLS. This is the role of EMS personnel and local medical teams in our opinion. The team physician should be prepared to initiate basic life support measures and have the ability to engage the EMS system in a timely manner. Finally, when working with an NCAA team, the physician should always consider reviewing the yearly NCAA drug testing guidelines in consideration for possible testing of any medications that are part of the travel bag.
Traveling with a team is an exciting and rewarding opportunity for the team physician. Pretravel preparation of the well-stocked medical bag (in cooperation with the athletic trainer for bulkier items) can make the experience more enjoyable for all involved. Having the proper medications and equipment available creates confidence with athletes, trainers, and coaches, and makes the role of team physician critical for the success of a team. It is impossible to prepare for all scenarios while on the road and the selection of travel supplies is dependent upon both clinical and team travel experience. However, in our opinion, it is better to be a bit overprepared with supplies than running to a pharmacy out of state. Finally, when preparing for a trip, do so in advance so that the proper medications and supplies can be ordered, and the bag can be organized neatly holding everything that is desired. We hope that this monograph is a helpful starting point for those who will be involved in these athletic team travel "adventures."
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6. Sideline preparedness for the team physician. American Orthopaedic Society for Sports Medicine web site. Available at: http://www.aossm.org/wnew/default.htm. Accessed April 22, 2003.
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The authors would like to acknowledge the support and assistance of Lee Arugubright, RN, clinical director, Lobo Clinic, with the preparation and maintenance of the UNM Lobos medical travel bag. The authors would also like to acknowledge the support and assistance of David Binder, ATC, head athletic trainer, UNM in our sports medicine activities.