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Editor's Note: Ryan T. Tierney, PhD, ATC, is an assistant professor in the Department of Kinesiology and Graduate Athletic Training Program Director at Temple University.
Face mask removal is a salient issue for the athletic training profession. The unique interaction of airway access and athletic equipment makes it part of our domain. The task is important because of the potential consequences of failure, but it is also important because it allows us to display a skill unique to certified athletic trainers. As such, it is necessary that we research and understand those factors influencing the success of face mask removal.
My overall impression of this article is very favorable. The authors did a commendable job of identifying and studying many unique factors that could influence face mask removal. Specifically, they identified the best tool to use (ie, cordless screwdriver) and studied environmental and usage factors that may influence the effectiveness of removal. The take-home messages were that consistent helmet reconditioning and maintenance involving hardware and the use of weather-resistant screw types are important. Therefore, their recommendation for a global standard for helmet recertification on an annual basis was appropriate.
Two areas lack significant discussion in the article. First, what is the scope of the problem regarding face mask removal during on-field emergency situations? Is the incidence of failures known? Second, were there certain characteristics of the high schools with failure rates close to or above 50% that may have influenced the rates? I believe this information, in addition to the current body of knowledge on face mask removal presented by the authors, will enhance the quality of emergency care provided to football players.
We thank Dr Tierney for his insightful commentary on our paper. Dr Tierney has raised some excellent points that deserve consideration. We would also like to thank the Journal of Athletic Training for allowing us the opportunity to respond.
The results of this specific study demonstrated that helmets (1) fitted with stainless steel or nickel-plated carbon steel and (2) that had been reconditioned more recently had higher face mask removal success rates than those fitted with less corrosion-resistant hardware and that had not been reconditioned as recently. The recommendation for global use of corrosion-resistant hardware and regular maintenance and reconditioning was a logical conclusion to make based on those findings. However, the extent to which these recommendations can be carried out is of concern, because reconditioning and recertification of helmets is not an inexpensive undertaking. Often helmets are reconditioned on a rotating basis to allow schools to afford the associated costs. If annual reconditioning of all helmets that are used regularly throughout the season is not a financial possibility for some programs, in our opinion, the use of corrosion-resistant hardware is an imperative first step to be taken and, based on our results, is likely the more important priority. Although higher quality hardware often is more expensive than carbon steel and can add to the cost of the reconditioning process, the added cost may be less than $1 per helmet. Based on data from this study and others we have performed (involving well over 3000 helmets), we believe strongly that the use of corrosion-resistant hardware is the most important factor in reducing the possibility of face mask removal failure. Performing simple maintenance throughout the season (eg, removing foreign substances embedded in screw heads, replacing damaged hardware) should also help to decrease the chances for face mask removal failure.
Dr Tierney also raises an excellent point when he inquires as to what the incidence of face mask removal or face mask removal failure actually is. We are not aware of any data addressing this issue that have been reported. Obviously, as with catastrophic injury, the call for emergency face mask removal is not a daily occurrence, but Dr Tierney is correct that the consequences of failure are negative. Through our line of research, we have attempted to identify the face mask removal approach that succeeds in the 2 main performance criteria for this task: reduced removal time and limitation of motion associated with removal. The removal of the face mask in as short a time period as possible ensures rapid airway access and the ability to provide artificial respiration. Reduction of movement associated with face mask removal is extremely important in the avoidance of iatrogenic injury to the spinal cord. Because the cordless screwdriver has been shown to reduce both time and movement associated with face mask removal, we have recommended that athletic trainers use a cordless screwdriver as their primary tool. However, because a cordless screwdriver can fail to remove one or more screws, we also recommend that athletic trainers carry an appropriate cutting tool. We have identified the most important cause of screwdriver failure and have made recommendations to improve screwdriver success rates. Papers on 2 separate projects investigating the combined-tool approach we recommend are currently under review; we feel both papers will provide support for this approach.
Dr Tierney also wonders if there were characteristics of the schools with high failure rates that might set them apart. The answer to that again comes back to the hardware (screws, T-nuts). Through inspection of the data, these schools in large part used carbon steel screws without a nickel-plated coating. Anecdotally, many helmets from these schools appeared to have been very poorly maintained in general but especially with regard to their rusty and otherwise degraded screws. Differences in failure rates did not appear to be based on school enrollment or staffing, including the self-reported presence or absence of a certified athletic trainer working with the team.
Ultimately, the key to an efficient and successful emergency response in the event of a cervical spine injury is preparation. Athletic trainers already practice the necessary techniques and skills associated with emergency management of cervical spine injuries, but we can further prepare for successful face mask removal through regular maintenance and by ensuring the use of corrosion-resistant hardware in football equipment.