In March 2000, the National Athletic Trainers' Association (NATA) issued a document called "Recommendations and Guidelines for Appropriate Medical Coverage of Intercollegiate Athletics (AMCIA)," which addresses the adequacy of sports medicine care that an institution provides to its student-athletes. The guidelines also serve as a beneficial starting point in assessing an NCAA school's current level of sports medicine care and any needed improvements.

NATA encourages NCAA schools not to view the guidelines as mandates but as recommendations. Although NATA does not intend those recommendations to create a new legal standard, the guidelines do have potential legal implications that NCAA members need to fully understand. Regarding the provision of sports medicine care to student-athletes, there is an important distinction between what "should" be done as a matter of medical optimality and what is "required" as a legal obligation.

As a general rule, an institution must use reasonable care in conducting its intercollegiate athletics program to prevent foreseeable harm to its student-athletes. This broad standard establishes a university's legal duty of care that must be satisfied to avoid potential liability for negligence. However, it often is difficult to determine exactly what must be done to constitute the exercise of reasonable care.

Without a federal or state statute establishing specific standards, determining what an institution must do to satisfy its legal duty of reasonable care requires careful consideration of both the benefits to student-athletes and financial ramifications to its sports medicine program. In other words, an NCAA member must implement a cost-effective (that is, reasonable) sports medicine program that adequately protects the health and safety of its student-athletes. An institution does not have a legal duty to provide more than a reasonable level of sports medicine care, although it may choose to do so.

No legal precedent

In evaluating whether a school's sports-medicine program complies with the legal standard of "reasonable," a number of factors are relevant. For example, the NCAA's Sports Medicine Handbook provides guidelines that offer some evidence of reasonable care. Health care provider organizations' recommendations, such as the AMCIA guidelines, also are relevant evidence to be considered. However, guidelines ordinarily do not establish the legal standard of reasonable care for sports medicine programs unless they have an accepted medical or scientific basis and are a cost-effective means of protecting student-athletes' health and safety.

Currently, there is no clear legal precedent establishing the required specifics of an NCAA school's sports medicine program. There is, however, potential legal liability if an institution's failure to develop and implement appropriate emergency medical assistance procedures causes a student-athlete to suffer injury or death.

In the 1993 case Kleinknecht v. Gettysburg College, a federal appellate court, applying Pennsylvania law, held: "[a] college ... has a duty to be reasonably prepared for handling medical emergencies that foreseeably arise during a student's participation in an intercollegiate contact sport for which a college recruited him."

This case involved allegations that the death of a male athlete who collapsed during a varsity lacrosse practice and suffered cardiac arrest was caused by the school's negligent emergency medical assistance procedures and first-aid treatment. The team's coaches were present during the practice but were not certified in cardiopulmonary resuscitation. No athletic trainer attended practice, and the nearest telephone was approximately 200 to 250 yards away from the practice field. The athlete had no medical history of heart problems and had been medically cleared to play lacrosse by both the team physician and his family physician. An autopsy did not reveal that the athlete had a heart abnormality.

At least in the context of an NCAA institution's legal duty to provide emergency medical care, the Kleinknecht court held that a special relationship exists between a university and its recruited athletes. Although lacrosse is a nonrevenue sport, the court maintained that the college recruited the player for its own benefit, hoping that the success of the lacrosse program would lead to favorable publicity and increased applications from potential students. Although his heart attack was unforeseeable under the circumstances, the court held that the possibility of severe and life-threatening injury is reasonably foreseeable during contact sports. It ruled that the reasonableness of the college's existing emergency response plan and first-aid treatment, as well as whether the existence of reasonable measures would have prevented the athlete's death were subject to review by a jury.

Deploying athletic trainers

NCAA Sports Medicine Guideline 1a-11 recommends that each institution establish an emergency medical plan for all sponsored intercollegiate athletics events, practices and skill-instruction sessions. This guideline recommends the presence of a delegated person who is qualified to render emergency care to a stricken student-athlete, but does not require this person to be a certified athletic trainer. It also recommends planned access to a telephone, emergency equipment, a physician and a medical facility. If adopted, these measures would appear to remedy the alleged inadequacies of the emergency medical plan cited in the Kleinknecht case.

While generally endorsing the NCAA's emergency medical plan guideline, the AMCIA guidelines recommend that a certified athletic trainer or an athletic trainer with equivalent qualifications be physically present at all practices for designated "increased-risk" sports, and that a certified athletic trainer be able to respond to an emergency within four minutes for "moderate-risk" sports. Those guidelines also recommend that a certified athletic trainer directly supervise all full-service athletic training facilities during institution-declared hours of service and be physically present during all home competitions for certain designated sports.

The Kleinknecht case did not rule that an NCAA university sponsoring intercollegiate sports has a legal duty to have a certified athletic trainer present at all games, practices and training sessions or be able to respond to a medical emergency involving a student-athlete within a particular period of time.

In litigation arising out of the death or injury of a student-athlete because of an alleged inadequate emergency response plan, the student-athlete's attorney may assert that an institution's noncompliance with AMCIA guidelines requiring the presence or availability of a certified athletic trainer constitutes negligence. Because those guidelines have been formulated by a national organization with special expertise in emergency sports medicine, a jury may give them substantial weight. However, AMCIA guidelines do not necessarily establish the legal standard of reasonable care that NCAA institutions must comply with, particularly if the economic costs of implementing them outweigh the foreseeable potential harm that student-athletes may experience while participating in sports events and practices or training activities.

Other legal implications

The law has not yet clearly defined the nature and scope of an NCAA institution's legal duty to provide non-emergency medical care to student-athletes. In Searles v Trustees of St. Joseph's College (Maine 1997), the Maine supreme court held that a university has a legal duty to exercise reasonable care for the health and safety of its student-athletes, which imposes an affirmative obligation to establish a sports medicine program that provides an adequate level of care. However, in Orr v Brigham Young University (1997), a federal appellate court, applying Utah law, rejected the Kleinknecht court's holding that there is a special relationship between a university and its student-athletes that creates an affirmative legal duty to take reasonable measures to protect their health and safety. At present, the law is not well-established concerning an NCAA institution's legal duty to provide student-athletes with non-emergency medical services typically provided by certified athletic trainers such as injury prevention, evaluation, treatment and rehabilitation services as well as return-to-play recommendations. Nevertheless, an institution generally is legally liable for negligent acts by its sports medicine personnel, including certified athletic trainers and student trainers, that cause injury to student-athletes.

Relevant approaches

In an effort to ensure that adequate sports medicine care is provided to all intercollegiate athletes on a program-wide basis, AMCIA guidelines develop a formula for quantifying the minimum number of certified athletic trainers that should be employed by a college or university. Relying on current literature and a variety of compiled general data on intercollegiate sports injuries, AMCIA guidelines recommend that an institution employ one full-time certified athletic trainer per 12 health care units as determined by their formula.

An NCAA institution is not necessarily required to employ a minimum number of certified athletic trainers to satisfy its legal obligations regarding the provision of adequate sports medicine care to its student-athletes. Although AMCIA guidelines "provide a rule of thumb" for intercollegiate sports medicine coverage, they do not consider the financial costs that NCAA institutions would incur in implementing their recommendations.

The AMCIA guidelines also propose a limited role for student athletic trainers in providing sports medicine care because they are not as well-qualified as certified athletic trainers. This certainly is true, and a university may be liable for negligent medical treatment rendered by its student athletic trainers. However, depending upon the specifics of state medical practice statutes, properly trained and supervised student athletic trainers could be used as part of a sports medicine program to satisfy an NCAA institution's legal duty to protect the health and safety of its student-athletes.

Even if financial constraints or other factors prevent an NCAA institution from strictly complying with the AMCIA guidelines, careful consideration of them will assist in ensuring the provision of adequate and high-quality sports medicine care to student-athletes. It is important to note that an institution's mere compliance with AMCIA guidelines requiring a minimum number of certified athletic trainers is not a safe harbor from legal liability. Determination of an institution's negligence liability depends upon the adequacy and quality of care provided by its sports medicine personnel during the specific circumstances surrounding a student-athlete's care.

The key issue faced by each NCAA institution is how to provide medically adequate and high-quality sports medicine care to all its intercollegiate athletes within the financial constraints of its athletics department budget. Some reallocation of financial resources may be necessary to satisfy legal requirements and ethical obligations to student-athletes. Each institution's president and athletics director should consult with their sports medicine staff, risk-management personnel and legal counsel in developing an appropriate sports medicine care program for student-athletes.

Matthew J. Mitten is a professor of law, director of the National Sports Law Institute at the Marquette University Law School and a member of the Committee on Competitive Safeguards and Medical Aspects of Sports. The views expressed herein are solely those of the author and do not constitute legal advice or an opinion of the Committee on Competitive Safeguards and Medical Aspects of Sports.