Studies of school and college sports show that no state requires an athletic trainer at high school events, that trainers, emergency plans and defibrillators are unevenly present, and that who has them tracks school income, distance from trauma care and, in several data sets, the racial makeup of the student body.Studies of school and college sports show that no state requires an athletic trainer at high school events, that trainers, emergency plans and defibrillators are unevenly present, and that who has them tracks school income, distance from trauma care and, in several data sets, the racial makeup of the student body.

Coverage of athlete health usually begins after something has happened to a person with a name. This feature begins earlier and lower, with the people, plans and equipment that sit on a sideline before anyone needs them. MB does not discuss the health of any named athlete and does not report injury updates. Everything below is about populations and systems.

The practical question is simple. When a teenager or a college student collapse during a practice, four things shape the first minutes: whether someone trained is present, whether a written emergency plan exists and has been rehearsed, whether a defibrillator is within reach, and whether the screening that preceded the season was able to find the problem. Awareness coverage of sudden cardiac arrest tends to stop at the first item. This article asks who actually those layers has, how access differs by school resources and by the demographics of the school, and where the research runs out. The angle is new for MB because it treats the sideline as infrastructure that some communities have and others do not.

AN ILLUSTRATIVE SCENARIO (NOT A REAL PERSON)

This is a composite built to organize questions. It is not a real school, a real athlete, or anyone MB interviewed, and it does not describe the practice of any actual district.

Two high schools in the same state play each other on a weeknight. At one, a certified athletic trainer arrives before warm-ups, the written emergency plan names who calls for help and who fetches the defibrillator, and the plan was walked through before the season. At the other, a coach holds a first-aid card, a defibrillator hangs in the main office at the far end of the building, and nobody has checked whether the field gate opens from the inside.

Nothing in this scenario says that either school is careless. It shows how two schools in one league can hold different amounts of protection without anyone having decided that they should. The sections below ask what the research says about how often that happens.

What a sideline is made of

A 2007 inter-association task force convened by the National Athletic Trainers’ Association, with participation from groups representing athletic medicine, emergency care and cardiology, issued a consensus statement on how high school and college programs should prepare for sudden cardiac arrest. It lists the elements of an emergency action plan: an effective communication system, trained responders in cardiopulmonary resuscitation (CPR) and defibrillator use, access to an automated external defibrillator (AED) for early defibrillation, the necessary emergency equipment, coordination with the local emergency medical services system, and practice and review of the plan.[10] The statement is a consensus document. It describes what programs should do, not what they do.

The person: no state requires an athletic trainer

Certified athletic trainers are health professionals who work at practices and games. A 2025 cross-sectional study sent a 17-question survey to the state high school athletic associations of all 50 states and the District of Columbia and heard back from 48. Eleven (23%) had sideline coverage mandates: three were risk-independent and eight applied only to sports considered higher risk. Thirty-seven (77%) had no mandate. No state required an athletic trainer to be present at high school athletic events. The authors calculated that 92% of high schools in the country are in states without a formal requirement for sideline medical coverage.[3] The survey asked about written requirements, so it cannot say how many schools provide coverage voluntarily.

So who has a trainer? A 2025 national analysis combined three databases covering 10,983 public schools. It found that 43.8% had no athletic trainer, 23.5% had a part-time trainer and 32.7% had a full-time trainer. Schools with full-time trainers had higher median household income and fewer students eligible for free or reduced-price lunch. Schools with a full-time trainer averaged 31.3% non-White students, compared with 46.0% at schools with none.[1] The study is cross-sectional and descriptive. It shows that the groups line up with income and school demographics. It does not show why.

California offers a closer look because it is the only state that does not regulate the athletic training profession, according to the authors of a 2024 survey of 1,538 secondary schools. More than half (51.6%) did not employ a certified athletic trainer, and 8.3% employed unqualified personnel as trainers. Nearly half (43%) of student-athletes were enrolled at schools with no certified trainer. Schools with certified trainers had a lower proportion of students eligible for free and reduced-price meals, and the average percentage of Hispanic or Latino students was greater at schools with no certified trainer and at schools that employed unqualified personnel.[2]

Geography adds a second pattern. In Virginia, a survey of athletic directors and athletic trainers found that rural communities had less access to an athletic trainer during practices and competitions and a longer wait before an injured athlete saw a sports medicine specialist when follow-up care was needed.[4] A national analysis of 18,244 schools measured the distance to a tertiary trauma center. Three-quarters were within 50 miles. Schools within that distance had 2.74times the odds of access to athletic training services (95% CI 2.56 to 2.93), and schools more than 60 miles away had decreased access.[5]

The picture is not uniform, and the exceptions matter. A study of 426 Indiana secondary schools found that the proportion of non-White students was greater in schools with more athletic trainer availability, not less. In the same data set, availability was greater in larger schools and in counties with higher graduation rates, and lower in counties with a higher percentage of residents without health insurance and a higher share with severe housing problems.[6] That result does not contradict the national one. It shows that a single state can carry a different pattern, and that school size, county resources and local decisions all act on the same outcome. The consistent finding across these studies is the link to resources. The link to race and ethnicity depends on the data set.

The plan and the defibrillator

A written plan costs little compared with a full-time salary, which makes it a useful test of whether protection is evenly spread. The evidence is older and thinner. A 2020 survey of secondary school athletic trainers reached 1,136 of 9,642 invited, an 11.7% response rate. Athletic trainers in states that required schools to adopt an emergency action plan reported including more of the recommended components (mean 8 versus 7). Schools in states that required both an emergency plan and CPR/AED training reported higher CPR/AED training implementation (95.5%) than states that required only CPR/AED training (81.6%; prevalence ratio 1.10, 95% CI 1.01 to 1.20).[7] Respondents were athletic trainers, so the figures describe schools that already employ one.

State-level surveys of school administrators tell a similar story from the other side. In Ohio, which had passed legislation in 2004 for optional public funding of AEDs in high schools, 264 of 827 member schools answered a survey. Fifty-three percent had an emergency plan for cardiac arrest, and 57% of those had rehearsed it. Twenty-five episodes of AED use at 22 schools over 11 years were reported, with a reported survival rate of 60%.[8] In Vermont, a rural state, all 74 high school athletic directors responded. Eighty-one percent had at least one AED on school premises, and larger schools were more likely to have one. Fifty-five percent had an emergency plan for cardiac arrest.[9] Both surveys are more than ten years old and rely on self-report, so they are not a picture of 2026. They suggest that owning a device is more common than having a rehearsed plan to use it.

What the surveillance data show, and what they do not

Sudden cardiac death in athletes is rare, and rare events are hard to count. There is no mandatory national reporting system, so researchers assemble cases from several sources. A 20-year study of National Collegiate Athletic Association (NCAA) athletes from 2002 to 2022 identified 143 sudden cardiac deaths among 1,102 deaths over about 9.1 million athlete-years, an overall incidence of 1 in 63,682 athlete-years. The incidence was higher in male than in female athletes (1 in 43,348 versus 1 in 164,504) and higher in Black than in White athletes (1 in 27,217 versus 1 in 74,581). The incidence rate ratios were 3.79 for male versus female and 2.79 for Black versus White athletes. Basketball and football had the highest incidence by sport, and the rate of sudden cardiac death fell over the 20 years (5-year incidence rate ratio 0.71) while non-cardiovascular deaths heldsteady.[11] An earlier decade-review from the same research network, covering 2003 to 2013, reported a Black versus White incidence rate ratio of 3.2.[12]

Three limits in these studies deserve plain statement. First, the authors of the 20-year study note that race was determined from media reports or photographs when no autopsy or medical examiner report was available. Second, they say that they lack data on resuscitated cardiac arrests and on screening practices, so they cannot say what caused the decline. Their discussion suggests that better screening, emergency plans and survival after arrest may all contribute, but the study did not test any of them.[11] Third, group labels such as Black and White describe how athletes were recorded in NCAA ethnicity reports and case review. The authors say it is unclear why basketball remained associated with higher risk after accounting for sex and race, and that this needs further scientific inquiry. A recorded race is a marker in a data set. It is not an explanation, and none of these studies measured the structural conditions that could produce a gap.

One more finding bears directly on the sideline. A two-year prospective surveillance study of exercise-related cardiac arrest in young athletes identified 132 cases, aged 11 to 27, of which 59% occurred in high school athletes. Overall survival was 48%. Survival was 60% (40 of 67) in White non-Hispanic or Latino athletes and 33% (13 of 39) in Black or African American athletes, a difference of 27 percentage points (95% CI 7 to 45). Ninety-three percent of cases were witnessed. When a certified athletic trainer was on site and involved in the resuscitation, 83% of athletes survived, and when an on-site AED was used, 89% survived.[13] The case counts are small and the study did not record which athletes had a trainer or a device available before the event. It therefore cannot say that unequal access explains the survival difference. What it does show is that survival after arrest differed in this sample, and that the cases with a trainer or a device on site had high survival, which are the layers that schools and leagues can build. The study does not identify which part of the response differed between groups.

The physical before the season

The pre-participation evaluation, often called a sports physical, is the fourth layer. A 2024 review in a primary care journal notes that the evaluation is considered standard of care based on expert opinion, and that six professional societies published a monograph to guide it.[17] A 2025 systematic review of guidelines and consensus statements found 35 documents of generally low quality and extracted 305 recommendations, of which 12.8% were directly linked to evidence from primary studies. The authors attribute this to a lack of primary studies on the effects of screening on health outcomes.[16]

Where evidence does exist, it concerns the test, not the access. A 2017 evidence-based review of 15 articles covering 47,137 athletes reported that an electrocardiogram (ECG) had a sensitivity of 94%, compared with 20% for the history and 9% for the physical exam.[14] A 2026 meta-analysis of 18 studies of 27,891 NCAA athletes found that 66 (0.24%) were diagnosed with a condition associated with serious morbidity or sudden cardiac arrest. ECG detected 3.5 times as many true positive cases as history and physical alone, but the false positive rate for the history and physical was 17% versus 5% for ECG.[15] The NCAA 20-year study notes that the association requires pre-was 17% versus 5% for ECG.[15] The NCAA 20-year study notes that the association requires pre-participation cardiovascular screening but not an ECG, and that one report found 56% of Power 5 schools used an ECG. The authors write that it is unknown how often an ECG is used at less-resourced institutions.[11]

The link to primary care is the part of the system with the least direct evidence in what MB retrieved. A study of about 800 student-athlete forms in one Texas school district found that 183 forms indicated an athlete had failed the visual acuity or cardiovascular portions. The authors describe mass screening as a possible safety net for athletes who may not have a primary care provider and call for follow-up with a regular clinician.[18] That is the authors’ interpretation from one district. A separate national survey of secondary school athletic trainers (380 respondents, a 6.7% response rate) found that 67.4% agreed that a patient’s socioeconomic status affected referral decisions, and 61.5% named type of health insurance as a barrier to care for patients with low socioeconomic status.[19] These are perceptions, not measured outcomes. They point at a question the literature has not answered: when a sports physical finds something, who makes sure the family reaches the follow-up appointment?

Putting the layers side by side

Layer

What the retrieved studies show

What they cannot show

Athletic trainer

No state required one; 43.8% of 10,983 public schools had none; access tracked income and distance from trauma care.[1][3][5]

Why schools differ, and whether a trainer changes survival in a given school.

Emergency plan

Required plans were associated with more recommended components; fewer than 60% of surveyed Ohio and Vermont schools reported a plan.[7][8][9]

Current national prevalence, or differences by school demographics.

AED

81% of Vermont schools had one; Ohio reported 60% survival in 25 uses.[8][9]

Whether devices are placed and maintained evenly across districts.

Pre-participation exam

ECG detects more than history and physical alone; recommendations are mostly low quality.[14][15][16]

Whether a flagged finding leads to follow-up care, and for whom.

Outcomes

In NCAA athletes, incidence differed by sex, race and sport; in a 2-year study of young athletes, survival differed by race.[11][13]

Whether differences in access to the layers above explain them.

WHAT THE EVIDENCE CAN AND CANNOT TELL US

It can tell us that no state required a trainer at high school events in a 2025 survey, and that trainer access is lower in lower-income schools, farther from trauma centers, and, in some national and state data, in schools with larger shares of students of color.[1][2][3][5]

It cannot tell us how many schools in 2026 have a rehearsed plan and a working AED, because the available surveys are older, regional, or have low response rates.[7][8][9]

It can tell us that sudden cardiac death incidence in NCAA athletes differed by sex, race and sport, and that survival in a two-year youth study differed by race.[11][13]

It cannot tell us that unequal access to trainers or devices caused those differences. None of the surveillance studies recorded the sideline resources present at each event.

It cannot tell us anything about any individual athlete, and MB draws no conclusion about any named person.

Questions to ask before the season

Anyone can ask these without medical training. They open a conversation about the system and do not imply that any school is failing.

QUESTIONS WORTH ASKING

Is a certified athletic trainer present at practices, at games, or both? If not, who is the first responder?

Is there a written emergency action plan for each venue, and when was it last rehearsed?

Where is the nearest AED to the field and the gym, and who checks that it works?

Does the plan name who calls emergency services and who meets the ambulance at the gate?

For away games and community leagues, who is responsible for these items, the home school or the league?

If a sports physical finds something, who tells the family and who confirms the follow-up visit?

What MB will ask next

MB will ask state associations and districts what they require and what they track. It will ask whether anyone records which schools have a trainer, a rehearsed plan and a working defibrillator, and whether the answer is shared with families. It will ask who pays for each layer, and whether a school can add a plan this year without adding a salary. It will ask how a sports physical connects to a regular clinician.

General information, not individual medical advice. For emergencies, seek immediate help. The conversation continues.

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SOURCES (PEER-REVIEWED WORK RETRIEVED FROM PUBMED; DOI LINKS INCLUDED)

[1] Rivera MJ, Willis A, Ramos O, Young JP, Barter EW, Post EG, et al. Relationship between athletic trainer access, socioeconomic status, and race and ethnicity in United States secondary schools. J Athl Train. 2025;60(1):82-87. DOI: https://doi.org/10.4085/1062-6050-0135.24 (PMID 39136089). Cross-sectional database study of 10,983 public schools.

[2] Eason CM, Goble SE, Post EG, Huggins RA, Casa DJ, Stearns RL. Factors influencing athletic training services in California secondary schools: a 5-year update. J Athl Train. 2024;59(11):1132-1138. DOI: https://doi.org/10.4085/1062-6050-0187.24 (PMID 38835328). Cross-sectional survey, 1,538 schools.

[3] Allen M, et al. Variation in state policies on sideline medical coverage of high school athletic events. Orthop J Sports Med. 2025;13(11):23259671251394044. DOI: https://doi.org/10.1177/23259671251394044 (PMID 41322040). Survey of state athletic associations, 48 of 51 responding.

[4] Thuesen S, Rogers M. Rural-nonrural disparities in sports medicine access in secondary school athletics in Virginia. Curr Sports Med Rep. 2025;24(1):4-8. DOI: https://doi.org/10.1249/JSR.0000000000001220 (PMID 39749951). Survey of athletic directors and athletic trainers; abstract reviewed.

[5] Yoshihara A, Olson MB, Filep EM, Kim D, Eason CM, Casa DJ, Huggins RA. Geographic disparity in distance to trauma care in secondary schools across the United States. J Athl Train. 2024;59(5):458-464. DOI: https://doi.org/10.4085/1062-6050-0149.23 (PMID 37734731). Cross-sectional, 18,244 schools.

[6] Rivera MJ, Post EG, Eberman LE. The social determinants of health and athletic trainer availability in Indiana secondary schools. J Athl Train. 2024;59(4). DOI: https://doi.org/10.4085/1062-6050-0737.21 (PMID 37655802). Cross-sectional database analysis, 426 schools.

[7] Scarneo-Miller SE, Kerr ZY, Adams WM, Belval LN, Casa DJ. Influence of state-level emergency planning policy requirements on secondary school adoption. J Athl Train. 2020;55(10):1062-1069. DOI: https://doi.org/10.4085/1062-6050-118-19 (PMID 32818958). Cross-sectional survey, 11.7% response rate.

[8] Lear A, Hoang MH, Zyzanski SJ. Preventing sudden cardiac death: automated external defibrillators in Ohio high schools. J Athl Train. 2015. DOI: https://doi.org/10.4085/1062-6050-50.8.01 (PMID 26381367). Cross-sectional web survey, 264 of 827 schools.

[9] Wasilko SM, Lisle DK. Automated external defibrillators and emergency planning for sudden cardiac arrest in Vermont high schools: a rural state’s perspective. Sports Health. 2013. DOI: https://doi.org/10.1177/1941738113484250 (PMID 24427431). Cross-sectional survey, 74 of 74 schools.

[10] Drezner JA, Courson RW, Roberts WO, Mosesso VN, Link MS, Maron BJ. Inter-association task force recommendations on emergency preparedness and management of sudden cardiac arrest in high school and college athletic programs: a consensus statement. J Athl Train. 2007;42(1):143-158 (PMID 17597956; PMC1896083).

[11] Petek BJ, Churchill TW, Moulson N, Kliethermes SA, Baggish AL, Drezner JA, et al. Sudden cardiac death in National Collegiate Athletic Association athletes: a 20-year study. Circulation. 2023;149(2):80-90. DOI: https://doi.org/10.1161/CIRCULATIONAHA.123.065908 (PMID 37955565). Retrospective and prospective surveillance; full text reviewed.

[12] Harmon KG, Asif IM, Maleszewski JJ, Owens DS, Prutkin JM, Salerno JC, et al. Incidence, cause, and comparative frequency of sudden cardiac death in National Collegiate Athletic Association athletes: a decade in review. Circulation. 2015;132(1):10-19. DOI: https://doi.org/10.1161/CIRCULATIONAHA.115.015431 (PMID 25977310).

[13] Drezner JA, Peterson DF, Siebert DM, Thomas LC, Lopez-Anderson M, Suchsland MZ, et al. Survival after exercise-related sudden cardiac arrest in young athletes: can we do better? Sports Health. 2019;11(1):91-98. DOI: https://doi.org/10.1177/1941738118799084 (PMID 30204540). Prospective active surveillance, 132 cases.

[14] Winkelmann ZK, Crossway AK. Optimal screening methods to detect cardiac disorders in athletes: an evidence-based review. J Athl Train. 2017. DOI: https://doi.org/10.4085/1062-6050-52.11.24 (PMID 29154691). Review summarizing a meta-analysis of 15 articles.

[15] Conway JJ, Bennett D, Asif IM, Teramoto M, Toresdahl BG. Pre-participation cardiovascular screening among NCAA athletes: a systematic review and meta-analysis of 27,891 athletes. Br J Sports Med. 2026;60(5):379-387. DOI: https://doi.org/10.1136/bjsports-2025-110791 (PMID 41775513).

[16] Weise A, Könsgen N, Joisten C, Schlumberger F, Hirschmüller A, Breuing J, Gooßen K. Pre-participation evaluation of recreational and competitive athletes: a systematic review of guidelines and consensus statements. Sports Med Open. 2025. DOI: https://doi.org/10.1186/s40798-025-00837-6 (PMID 40188235).

[17] Wise MW, Cole C, Provance A. Preparticipation sports physical evaluation in adolescents. Prim Care. 2024;51(4):613-627. DOI: https://doi.org/10.1016/j.pop.2024.05.004 (PMID 39448098). Review; abstract reviewed.

[18] Bhardwaj N, Pierre GS, Halloran AP, Alexander TC, Leung SH, Lu Y, Campbell KM. Failure to participate in sports: an evaluation of preparticipation physicals in a local school district. J Am Board Fam Med. 2024;36(6):1033-1037. DOI: https://doi.org/10.3122/jabfm.2023.230098R1 (PMID 37857444). Retrospective review of about 800 forms, one district.

[19] Hernandez MI, Miller EC, Biese KM, Columna L, Andreae S, McGuine TA, et al. Secondary school athletic trainers’ perceptions of the influence of social determinants of health and socioeconomic status on clinical management decisions. J Athl Train. 2024;59(4):388-393. DOI: https://doi.org/10.4085/1062-6050-0445.22 (PMID 37459372). Online survey, 380 respondents, 6.7% response rate; abstract reviewed.