What It Feels Like to Die From Heat Stroke (Outside Magazine)

What It Feels Like to Die From Heat Stroke

By:Amy Ragsdale and Peter Stark 

End of the dirt road. You brake to a stop, swing your leg over the scooter, and kick the stand into place.

The effort makes your head throb. The scooter wobbles. Your sunglasses slide down the mixture of sweat and sunscreen on your nose. You adjust them, look up tentatively at the fiery orb in the deep blue sky, and flinch. You chide yourself for staying out so late the night before, for not getting an earlier start this morning. The sun already feels too hot. But this is your only chance to surf Emerald Cove. It’s gonna be OK, you tell yourself. You’re in good shape. You’ve got the stamina to hike the five miles over the ridge and down to the beach before the tide comes in.

That glaring sun, of course, is essential for life on this planet. But its thermal energy, which we feel as heat, is a force both benevolent and cruel. The human body employs a spectrum of physiological tricks to maintain the steady internal temperature—98.6 Fahrenheit—at which it thrives. There is about eight degrees of difference between an optimal level of internal heat and the limit the body can endure. This threshold is referred to as the critical thermal maximum. Exactly when one reaches it depends on individual physiology, exertion, hydration, acclimation, and other factors. Estimates place it at an internal temperature between 105 and 107 degrees. Heat is a giver of life, but when the human body gets this hot—or hotter—­terrible things occur.

Emerald Cove is on an island off the coast of South America. You’d flown over a couple of days ago, after a trek in the mainland’s cool interior highlands. You wanted to take in those thousand-year-old stone statues you’d heard so much about, plus you figured you could cap off your vacation with a couple days of surfing. You’re just a beginner, and already you’re hooked, but it’s hard being a newbie. The locals are reluctant to let you into the lineup. What you need is that perfect undiscovered break, no people, no pressure.

Last night you walked into a popular surf bar and pulled up a stool next to two guys you’d seen in the water that day. If you wanted to find a secret spot along this spectacular wave-battered coast, you figured these guys would be the ones to know. They gave you a cursory nod and continued their conversation.

“Huevón,” one was saying to his pal (or at least that’s what you think he said). Your Spanish is OK, but you’re not catching all the slang. He was talking about a point break.

“Qué bacán!” Rad! “And there’s nobody there. Nobody. You have to try it.”

“Nobody where?” you asked quietly, leaning in.

“La Cala Esmeralda.” He barely turned his head to look at you.

“Emerald Cove?” you repeated.

It had taken a long time, a lot of patience, and too many piscolaspisco and Cokes—to pry out where it was, but the effort was worth it. It’d be the perfect end to a perfect trip, something to talk about to your well-traveled friends back home. “Seriously, you’ve never been there?” you’ll say to them, acting surprised. “You should definitely check it out. But it’s kinda hard to get to, and the trail’s a secret.”

You had to ask the surfers to repeat themselves, just to be sure you understood. They’d finally turned and looked at you full on.

“Dude,” one said, “I’m not sure I’d try it if I were you.”

Heat-related illnesses in the U.S. claim more lives annually than hurricanes, lightning, earthquakes, tornadoes, and floods; there were over 9,000 heat-related deaths between 1979 and 2014. The fatalities tend to peak during heat waves and hotter-than-average years, and they’re expected to rise as climate change affects global temperatures. One of the deadliest heat waves in modern times swept Europe in 2003, killing over 30,000 people as temperatures soared to 100 degrees for days on end.

The human body is much less tolerant of rises in internal temperature than drops. The lowest body temperature a human has been known to survive is 56.7 degrees, nearly 42 degrees below normal. Anna Bagenholm, a 29-year-old Swedish woman, was backcountry skiing when she broke through eight inches of ice into a frozen stream. Her upper body was sucked down, leaving only her feet and skis visible, but she managed to find an air pocket and was able to breathe. After 80 minutes, she was finally rescued. Bagenholm remained in a coma for about ten days and was in intensive care for two months but ultimately suffered only minor nerve damage. On the other end of the spectrum, the highest body temperature measured was only 17 degrees above normal. Willie Jones, a 52-year-old Atlanta man, was rescued from his apartment during a heat wave in 1980. His internal temperature was 115.7. He spent 24 days in the hospital before being released.

While there is some debate, studies on women in the military have shown that they may be more susceptible to heat illness than men due to their higher body-fat content and lower sweat output. Whether the heatstroke victim is male or female, the odds of surviving depend on the duration of overheating and, once their condition is discovered, how quickly they can be cooled down—most effectively by immersion in ice water within 30 minutes. Survival, moreover, doesn’t guarantee full recovery. A powerful heat wave in Chicago in 1995 caused 739 deaths and 3,300 emergency-room visits. A study reviewing 58 of the severe heatstroke victims found that 21 percent died in the hospital soon after admission, 28 percent died within a year, and all the remaining subjects experienced organ dysfunction and neurological impairments.

An average-size male at rest generates about as much heat as a 100-watt light bulb simply through metabolism. During moderate exercise, temperature increases nearly ten degrees every hour unless you cool yourself by sweating or some other means. You risk a variety of illnesses, starting with heat edema, which entails swelling of the hands and feet and can begin at body temperatures close to normal. No precise temperature marks the onset of the various other heat illnesses, and the order of symptoms varies between individuals, but they may include heat syncope (dizziness and fainting from the dilation of blood vessels), heat cramps (muscular clenching due to low salt), and heat exhaustion (identified by muscular weakness, rapid heartbeat, nausea, headache, and possible vomiting and diarrhea). Finally, an internal temperature of 105 marks the lower boundary of heatstroke territory, with outward symptoms of extreme irritability, delirium, and convulsion. Because of individual variation in how these symptoms appear, and because some may not appear at all, athletes in particular can be overcome quickly and with little warning.

There are two kinds of heatstroke: classic and exertional. Classic heatstroke hits the very young, the elderly, the overweight, and people suffering from chronic conditions like uncontrolled diabetes, hypertension, and cardiovascular disease. Alcohol and certain medications (diuretics, tricyclic antidepressants, antipsychotics, and some cold and allergy remedies) can increase susceptibility as well. Classic heatstroke can strike in the quiet of upper-floor apartments with no air-conditioning.

Exertional heatstroke, on the other hand, pounces on the young and fit. Exercise drastically accelerates temperature rise. Marathon runners, cyclists, and other athletes sometimes push into what used to be known as the fever of exercise and is now called exercise-induced hyperthermia, where internal temperatures typically hit 100 to 104 degrees. Usually, there’s no lasting damage. But as body temperature climbs higher, the physiological response becomes more dramatic and the complications more profound. The higher temperature can ultimately trigger a cascading disaster of events as the metabolism, like a runaway nuclear reactor, races so fast and so hot that the body can’t cool itself down. A person careens toward organ failure, brain damage, and death.

It’s February, the height of summer in the Southern Hemisphere. You’d planned to get up early but didn’t hear your alarm after the late night at the bar. Now the sun is well into its arc. The temperature is supposed to hit 93 degrees by midday.

Pulling the keys from your scooter, you sling your rented surfboard onto your back, thread your arms through your chest pack, and hear the reassuring slosh of the water bottle inside. You have a seat on the twice-weekly plane that leaves tomorrow, returning you to the mainland. If you’re going to do this, the moment is now. You launch up the trail, a faint unmarked path on the gentle, grassy slope. You’re not surprised you’re the only one around. The surfers said to follow the volcano’s right flank until you gain the ridge, then drop down a cleft in the rocks to the sea. Good luck finding the cleft, they seemed to say. Maybe they were just trying to deter you. You see the slope steepen as it rises toward the sharp crest, where chunks of volcanic rock protrude like broken dinosaur scales through velvety green nap. No trees, not a wisp of wind. Ancient cultures deforested this island centuries ago and mysteriously disappeared, leaving not a sliver of shade under the tropical sun.

You feel the quick flex of your quads, the push of your glutes, the spring of your calves propelling you up the winding path, and hear the steady mantra of your breathing. You have to make time. The guys at the bar said the shore bristles with stone dientes, teeth—get there at low tide. That gives you just under two hours.

Within only a few steps, your body begins to respond to the sun’s radiation, the moist air pressing against your skin, and the heat generated by your own rising metabolism. Blood coursing through your arteries begins to grow warmer. At less than one degree Fahrenheit above your normal internal temperature, receptors in your brain’s hypothalamus start to fire, signaling the circulatory system to shunt more blood toward your skin’s surface for cooling. Other messages tell peripheral blood vessels to dilate, opening up to allow greater blood flow. Still other signals activate millions of tiny coils and tubes embedded in your skin—your sweat glands. Concentrated within your head, palms, soles, and trunk, the glands pump water from a tiny reservoir at the base, pushing the salty liquid up a long tube through layers of skin to erupt in a miniature gusher at the surface.

Several hundred yards up the grassy slope, sweat is popping onto your face. You feel the slick, dark blue fabric of your shirt sticking to your back, despite its breathability. You wish it was looser, and a lighter color that didn’t so readily absorb the sun’s rays. A trickle of sweat runs down your forehead and into one eye, stinging with dissolved salts, blurring your vision.

The air is smothering, thick with moisture, like a greenhouse. The dripping sweat should bring some relief. Usually, the body’s cooling system operates remarkably efficiently; blood rushes to carry the excess heat from your core out to your sweat glands, which squeeze warm fluids to the surface, where air moving past your skin evaporates the moisture. Your excess heat literally blows away in the wind. But for this to work properly, the sweat must evaporate. When the air lies close and unmoving, heavy with humidity, sweat evaporates more slowly. If the air is saturated enough, or if impermeable fabric—or, in your case, a surfboard and a chest pack—trap the sweat against your skin, the moisture won’t evaporate at all.

High school athletes are often afflicted by heatstroke, which ranks as one of the top three leading causes of death among that demographic. And according to an investigation done by the HBO show Real Sports with Bryant Gumbel, since the year 2000, at least 30 college football players have died of heatstroke during practice, when remedies as simple as immersing the overheated player in ice water were available. Minnesota Vikings offensive lineman Korey Stringer died of heatstroke during a preseason practice in 2001, and now the University of Connecticut’s Korey Stringer Institute, established in 2010, specializes in sudden-death prevention in athletes, soldiers, and laborers.

Runners, cyclists, and hikers routinely succumb to heatstroke. If properly acclimated, trained, and managed carefully, the human body can endure grueling events in high temperatures, like the Badwater—a 135-mile running race in California that begins in Death Valley, traverses three mountain ranges, and ends at Mount Whitney—and the six-day Marathon des Sables in the Sahara. However, experts say that due to the high intensity of the pace on shorter courses, heatstroke is more common in races of 30 to 90 minutes than in longer events. Three years ago at the annual Falmouth Road Race, a 12K running event in Massachusetts in August, 48 out of more than 10,000 finishers suffered from heatstroke and another 55 from heat exhaustion. (All of them survived without incident due to the extensive cooling procedures available at the race’s finish.)

The National Weather Service now issues warnings when excessive temperatures are expected and gives predictions of the heat index, which takes into account both temperature and humidity as experienced by a five-foot-seven, 147-pound person walking at a speed of about three miles per hour in a six-mile-per-hour breeze. Like the windchill index, the heat index conveys what it feels like outside. For instance, at the Hot Trot Half Marathon, which is held in Dallas in August, the day is often 97 degrees but can have a heat index of 116 degrees because of the 60 percent humidity.

You pull your water bottle from your pack—a full liter shimmering inside a translucent blue Nalgene—take a warm swig, and strike upward again toward the broken scales of the ridge. For the next hour you push at a fast walk, pausing only occasionally to drink. You know the importance of hydration. What you don’t know is how remarkably fast the human body can expel water to cool itself—one and a half liters or more per hour. (Highly efficient, heat-acclimated marathoners can lose close to four liters per hour while they run.) The human gut, however, can absorb only a little over one liter of water per hour. That means that during maximum rates of water loss, it’s possible to drink steadily and still become dehydrated.

Your core temperature has now climbed to 101.5—three degrees above normal—but you’re still in the exercise-induced hyperthermia zone. Your head throbs. You wish you hadn’t drunk quite so many piscolas last night. In doing so, you unwittingly tricked your body’s water controls. Alcohol is a small molecule that slides easily through the walls of the gut, into the bloodstream, and up into the brain, where it suppresses the release of antidiuretic hormone, or ADH. This is the hormone that inhibits urination, in effect closing your dam’s spillway in order to keep your reservoir full. Typically, when you become dehydrated, the percentage of salt in your blood rises, triggering your pituitary gland to release ADH. But under the sabotaging influence of alcohol, your body may sense that your water stores are being depleted but blithely ignore the warning. Thanks to those piscolas, rather than prehydrating for today’s climb, you started the day in the red.

The incline grows steeper. The grass gives way to a light, loose volcanic rock called tuff. The scrappy path has now completely disappeared, but still you labor toward the ridgetop—two steps up, slide, one step down. You’re panting now. The rocks crunch under your feet. Each footstep produces a gritty dust that crusts your bare legs, which are coated in a paste of sweat and sunscreen. The arteries protruding on your forearms look like grapevines wrapped around a post. Your blood vessels are dilating, trying to move as much overheated blood to the surface as possible. Your heart pumps madly, trying to keep the vessels full, but it can’t keep up. Not enough blood—and the oxygen it carries—reaches your brain. You pause to rest. You feel lightheaded and faint. Your vision dims and narrows. You feel wobbly and strange—the onset of heat syncope (or orthostatic hypotension), a temporary loss of consciousness from falling blood pressure.

Fainting from orthostatic hypotension poses a distinct problem for those whose sworn duty requires standing still for hours in the sun, as it does for Britain’s royal guards. In their bearskin hats and thickly layered uniforms, which are designed to hide sweat, they topple with surprising regularity flat onto their faces, breaking teeth and smashing noses, fainting at full attention with their arms and rifles still rigidly glued to their sides.

But you decide to sit on the rocks, and so you do not topple. You finish your water. You feel limp, like a wrung-out rag. You have a single thought: make it to the ridge and descend to the cool of Emerald Cove. Thirty minutes to go.

At one hundred three degrees internally, you’re pushing into the upper limits of exercise-induced hyperthermia and into heat exhaustion. Your brain is no longer able to deal with large numbers.

One hundred four. Get over the ridge, you tell yourself. Get over the ridge.

Above you the jagged lava rocks begin to distort, reshaping into those ancient giant stone statues erected along the island’s shore. They face you, their enormous heads silhouetted against the blue sky, as if to say, Go back!

But you don’t.

Over millennia, people exerting themselves in hot environments, like the nomadic Maasai of Kenya, have genetically adapted, selecting for tall, slender, long-limbed body types that offer the maximum ratio of cooling surface area to heat-generating body mass. You are not Maasai.

When you finally crest the ridge, your core temperature is pushing 105. You are weak, hot, and thirsty, and you are confused but don’t know it. Gazing back down the way you came, you see the dropping sweep of green. It seems surreal, removed and stylized, like an old hand-painted postcard. Just ahead, the cliff’s edge drops away to crashing ocean far below.

The guy at the bar had said that the top of the trail was marked by a divot where the rock is worn like a V. You walk carefully along the broken ridgetop, afraid to peek over the airy drop. Where’s the guardrail? Your body feels unwieldy.

Maybe it was a mistake to come here straight from the interior highlands, with their evening breezes and cool air. You’d heard that the human body needs time to fully adjust to heat. What you didn’t know is that it generally needs about 7 to 14 days. By gradually building your exercise time outdoors in heat and humidity, your body learns to activate its cooling response at lower temperatures. It learns to increase the rate of sweat production and to trigger a mechanism to conserve sodium, which, along with potassium, is essential for fluid regulation and transmission of nerve signals. (The evolution of this mechanism was honed by our hunter-gatherer ancestors, who struggled to consume enough sodium in their diets.) Acclimation would have slowed your heartbeat but boosted the volume of blood circulated with each contraction to help maintain your blood pressure as your vessels dilated.

But you didn’t acclimate. You relied on the fact that you exercise five days a week at home—also a hot, humid place in the summer. Your heat-addled mind drifts back to those summer days. Instead of this blazing light, you see the tinted windows of your SUV. Instead of this heat smothering your skin, you remember the hair-tingling chill of your car’s air-conditioning, the dim, dank spaces of a parking garage, the cold blasts washing over the treadmill in the climate-controlled gym. It begins to dawn on you that all your life you have relied on artificial sources to keep you cool. You’ve never had to change your behavior or alter your ambitious schedule to accommodate the natural diurnal cycle. You’ve always carried your bubble with you. You’ve never had to truly confront the punishing heat of the midday sun.

And then: you’ve found it! You see a scuffed notch on the ridgetop and, far below, the glint of water. This is why you came! Delirious, you begin to scramble down. You slip, skid on your side, dragging and scraping your hands. You regain your feet and steady yourself against smooth boulders, leaving a bloody handprint. The blood stain looks like a bird, you think, in acrylic paint, textured and thick—another effect of dehydration. Suddenly you notice that a bird (does it have four wings or six?) is swooping toward you, its talons reaching for your face. You try to swat the heat-induced hallucination away, first with your hands, then with your board, but it keeps coming back. You toss aside your board and stumble downward to get out of range.

You come to a ledge. Beyond it is pure drop and yes, there’s the beach, several hundred feet below. You just need to fly, you think foggily, but sense that you have no choice but to climb back up. Your chest pack feels impossibly heavy, as if you’re hauling the 13-ton head of one of those ancient statues. Irritated, you shimmy clumsily out of the straps and watch, mesmerized, as your pack tumbles over the edge and drops into the ocean.

Free at last, you begin to crawl back up. But you feel yourself sliding down the loose tuff. It’s so much easier than climbing. You give into the sensation of increasing speed, like a plane accelerating down a runway. You always loved that. You spread your wings and topple backward down the slope. As your head hits the tuff, you feel the coarse lava grit stick to the drying saliva of your lips and mouth. The ledge stops your descent. And then you feel no more.

It could be a small measure of good fortune that confusion, semiconsciousness, or coma overcome victims as they succumb to severe heatstroke. The damage about to ensue wreaks so much havoc that almost no major organ escapes untouched. At 105, your metabolism accelerates, so your cells generate heat at a rate that is 50 percent faster than normal. In other words, as your internal temperature rises, rather than cranking your air conditioner, you fire up your furnace. The only effective remedy is to douse the fires with immediate and extensive cooling.

Each heatstroke victim responds differently to these extreme internal temperatures, but a sequence of events might go like this: at 105 to 106 degrees, your limbs and core are convulsed by seizures. From 107 to 109, you begin vomiting and your sphincter releases. At 110 to 111, your cells begin to break down. Proteins distort. Liver cells die; the tiny tubes in your kidneys are grilled. The large Purkinje neurons in your cerebellum vanish. Your muscle tissues disintegrate. The sheaths of your blood vessels begin to leak, causing hemorrhaging throughout your body, including your lungs and heart. There is now blood in your vomit. You develop holes in your intestines, and toxins from your digestive tract enter your bloodstream. In a last-ditch effort, your circulatory system responds to all the damage by clotting your blood, thinking your vessels have been severed. This triggers what physicians call a clotting cascade.

As your insides melt and disintegrate, purple hemorrhagic spots appear on your skin. Those, the bloody vomit, and your convulsions are the only external hints of total internal annihilation.

“Is that a person down there?” the surfer from the bar asks his friend, skidding to a halt in their quick descent through the rocks.

Following the line of a pointing finger, the friend peers at a dark splotch on a ledge far below and a bit to the left, off the winding path and down through the steep rocks.

“Looks like that dude from the bar last night,” he continues.

They continue scrambling down toward the cove, their wide-brimmed hats flapping, surfboards strapped to their backs. As they get closer, they see it is you. They drop their boards and clamber across the rocky slope. When they reach you, you look dead—limbs askew, eyes staring. One of them touches your bare arm. The skin is clammy. He feels for a pulse. It’s faint and quick, like the heartbeat of a bird.

“He’s still alive,” he says. “But he’s way too hot,” he adds, shaking his head. “Let’s get him to the agua dulce.”

Lifting you carefully, they drape you over the stouter surfer’s back and shoulders. You’re several pounds lighter than your normal weight due to dehydration. They scramble down the precipitous path, kicking free tuff that bounces ahead. Ignoring the shimmering water and the sculpted waves curling off the point, they haul you across the beach to a grove of palms against the foot of a cliff. A spring spills from a crevice in the rocks into a clear, quiet pool. Agua dulce. Sweet water.

It’s much cooler than the tepid ocean—­almost cold. They slide your body in and hold you there, immersed, cradling your head above the surface. Two minutes pass, five minutes, ten.

“Está muerto,” says the stouter one.

“No,” says the other, carefully scooping handfuls of cooling water over your head.

Your eyes show a flicker of movement.

You hear splashing, faint at first, from somewhere far away. It comes closer, growing louder, until you realize that it’s right around your ears. You feel the sensation of cold all over your body. When you open your eyes, you can’t make sense of what you see—two faces framed by drooping palm fronds and deep blue sky.

“Descansa,” one says. Rest.

You close your eyes again. A hand brings water to your lips. You drink. You are lucky. With an internal temperature of 106, you peaked within your critical thermal maximum. It’s not yet clear what lasting damage you may have sustained, but you are alive.

Right now, however, all you know is that you’re so very tired. You’ll have to be carried out of here, by stretcher or helicopter or boat. Your thirst feels like a cavernous hollow at your core. You don’t know where you are or where you have been. You remember leaving the scooter and starting up a long grassy slope toward a volcanic ridge. After that there was only the relentless weight of the sun overhead, the heat-blasted lava rock underfoot, and the sense that you were being crushed between them with nowhere to run or hide, a fragile creature of flesh and bone, blood and water, trying to escape the enormity of this force that gives life but, you now understand, can so easily destroy it.

 

Link: https://www.outsideonline.com/2398105/heat-stroke-signs-symptoms

How to Prevent and Treat Heat Stroke (Outside Magazine)

How to Prevent and Treat Heat Stroke

Outside Magazine

By: Peter Stark

“The key thing for people’s outcome is the number of minutes their temperature is over 105 degrees,” says Douglas Casa, CEO of the University of Connecticut’s Korey Stringer Institute, named after the Minnesota Vikings offensive lineman who died of heatstroke during an August 2001 training camp. Survival is highly likely if the core temperature is brought below 104 degrees within 30 minutes. Here are Casa’s tips on prevention and treatment.

  1. Avoid exercising in high temperatures, or choose cooler parts of the day and stay in the shade. If you do exercise in the heat, wear pale-colored, loose-fitting, lightweight clothing, and acclimate to the conditions by gradually increasing your output over 7 to 14 days.
  2. How much water to drink is the subject of some debate. For recreational athletes, Casa suggests hydrating based on thirst. High-level endurance athletes should account for other factors, such as sweat rate. Avoid drinking alcohol before and during strenuous outings.
  3. Heatstroke symptoms vary. Many victims are still conscious, and some have seizures or vomit while others do not. Suspect heatstroke if the person can no longer support their body weight, speaks irrationally, or is hyper-irritable or confused. (Casa knows of heatstroke victims who punched a police officer at the finish line of a race.) To get a true reading of core temperature, use a rectal thermometer.
  4. “Cool first, transport second” is the oper­able concept when it comes to heatstroke. With mere minutes to act, a victim should be cooled down before being taken to an emergency room. Immersing the body in a cold bath lowers temperature the fastest, dropping it one degree every three minutes if the water is circulating.
  5. Exertional heatstroke in the backcountry presents additional challenges. Anything that cools the victim is helpful, but the best options are to immerse them in a lake, river, or stream, or wrap them in fabric drenched with ice water from a cooler. It’s important to cool as much of the body’s surface area as possible. In the absence of cold water, seek shade, wet the person’s clothing with your water bottle, and fan them. (For heatstroke prevention tips aimed specifically at desert hikers, go to Ariel’s Checklist.)

Link: https://www.outsideonline.com/2398185/how-to-prevent-treat-heat-stroke

 

After 2 boot camp deaths at Great Lakes base, Navy urges vigilance for recruits with sickle cell trait (Chicago Tribune)

Following two recent deaths during physical fitness testing, officials at the Navy’s Great Lakes training base are withholding people with “specific medical traits” from intense exercise pending further review.

A Great Lakes spokesman, citing privacy concerns, wouldn’t name those traits, but an administrative memo issued by the Navy suggests the focus is on sickle cell trait, a genetic blood condition that can pose a lethal danger during vigorous workouts.

The memo, released earlier this month, singles out the trait as a risk factor requiring extra vigilance. It instructs people leading fitness exercises to familiarize themselves with the condition and ask recruits about it before training. It also urges African-American personnel, who are disproportionately affected by it, to “engage with medical (staff) to determine their status and understand the risk.”

It’s not clear whether any particular medical condition was a factor in the deaths of the recruits at the north suburban base. Both collapsed at the end of a 1.5-mile timed run during their final physical readiness test of boot camp, and died while receiving treatment.

Kierra Evans, 20, from Monroe, La., died Feb. 22. Kelsey Nobles, 18, from Mobile, Ala., died April 23. Lake County Coroner Dr. Howard Cooper said the investigations into their deaths have not been completed. Neither of their families could be reached for comment.

The Navy memo said two sailors who were not at Great Lakes also died during physical training over the last year.

Sickle cell disease causes blood cells to harden, grow sticky and morph into a “C” shape. The cells can clog blood vessels, robbing tissues of oxygen and causing severe pain and the risk of sudden death.

Sickle cell trait, by contrast, is a genetic characteristic. Most who have it don’t experience the symptoms of the disease, though they can surface during hard workouts.

The Navy memo said two sailors who were not at Great Lakes also died during physical training over the last year.

Sickle cell disease causes blood cells to harden, grow sticky and morph into a “C” shape. The cells can clog blood vessels, robbing tissues of oxygen and causing severe pain and the risk of sudden death.

Sickle cell trait, by contrast, is a genetic characteristic. Most who have it don’t experience the symptoms of the disease, though they can surface during hard workouts.

The trait’s prevalence in African-Americans is well known — roughly 1 in 12 have it — but Dr. Victor Gordeuk, director of the sickle cell center at the University of Illinois Hospital in Chicago, said people with roots in Italy, Greece, Saudi Arabia, and other areas around the Mediterranean can have it, too (the trait helps people withstand malaria, he said).

He said people with the trait can have their cells deform dangerously during periods of intense exercise. Why that happens isn’t fully understood, he said. It often comes in tandem with heat illness, but not always.

“Some of the patients just have sudden collapse, loss of consciousness, loss of strength in their extremities,” he said. “Sometimes they can have painful cramps. We don’t fully understand the mechanism whereby that’s occurring.

“In some cases, on postmortem, the brain looks normal, the blood vessels look normal, but they’ve had this coma develop while they’re exercising. To a certain extent it’s a medical mystery, but we do know that people with sickle cell trait are at increased risk for this happening.”

The military has long recognized those risks. Researchers as far back as the 1960s have documented sickle cell-related deaths that occurred during the rigorous workouts of basic training. One study in the 1980s found that black Army recruits who had the trait were about 40 times more likely to suffer sudden death than recruits who were not black.

The services take varying precautions for recruits with the trait, according to military health researchers. The Navy screens everyone entering boot camp, and requires those with the trait to wear a red belt during strenuous exercise. Other branches use different identifiers or don’t screen for sickle cell at all, focusing instead on mitigating heat-related risks.

The Navy memo highlights a condition known as “exertional collapse associated with sickle cell trait,” or ECAST, that can strike some recruits.

“An ECAST victim may have been a front runner, or off to a strong start, but will be noted somewhere before the collapse as slowing down, falling behind and struggling,” it says. “They begin to lose smooth coordination, they evolve into an awkward running posture and gait, with legs that may look wooden or wobbly.

“The victim may complain of progressive weakness, pain, cramping or shortness of breath. … The ECAST victim will initially be mentally clear, before the onset of confusion and loss of consciousness.”

The memo says Navy officers should adopt a liberal “bad day” policy that allows people struggling with the physical readiness test to stop and try again after a medical evaluation.

“No one should risk their life by pushing through life-threatening conditions during a (physical test),” it says.

Great Lakes spokesman Lt. Cmdr. Frederick Martin said boot camp already follows the guidelines laid out in the memo, but that changes could come as a result of the investigation into the recruits’ deaths.

Douglas Casa of the Korey Stringer Institute at the University of Connecticut, which aims to prevent sudden death in athletes, helped craft a statement about treating sickle cell emergencies for the National Athletic Trainers’ Association. He said people with the trait can endanger themselves during high stakes physical tests, such as the 1.5-mile run Navy recruits must conquer in a set time to graduate from boot camp (women in their late teens, for example, have to finish in less than 14:45).

“If someone’s really struggling, no one should be pushing or screaming at them to continue,” he said. “They should stop and be protected. We really have to ask if (the 1.5-mile run) is the best way to evaluate the fitness of someone with sickle cell trait.”

By: John Keilman

jkeilman@chicagotribune.com

Twitter @JohnKeilman

Source: https://www.chicagotribune.com/news/ct-met-great-lakes-death-exercise-20190521-story.html

Study Examines Sudden Deaths in Youth Athletes (Athletic Business)

New research by the Korey Stringer Institute (KSI) and the University of Connecticut revealed the most common cause of sudden death in American youth sports for athletes aged 6-17 years.

According to a press release by the National Athletic Trainers’ Association, which published the first-of-its-kind study in its Journal of Athletic Training, the majority of sudden deaths among youth athletes were cardiac-related and took place during practices within organized middle school sports.

The research looked at data from 2007-2015, where there were 45 cases of sudden deaths reported in American youth sports. It found that sudden cardiac death accounted for 76 percent of those deaths. The researchers found that basketball was the most deadly sport, accounting for 36 percent of sudden deaths. Baseball and football each accounted for 16 percent of sudden deaths, and soccer accounted for 13 percent.

Fully 73 percent of sudden deaths occurred in kids between the ages of 12 and 14, and about 80 percent of the sudden deaths were boys.

“Until this study, sudden deaths occurring in youth sport had been grouped with sudden deaths occurring in older athletic populations in previous epidemiological studies,” Brad Endres, the study’s lead author and the assistant director of sport safety at KSI said. “Our goal was to clearly define the understanding of ‘youth sport’ so that more appropriate and evidence-based policy decisions aimed at improving youth sport safety can be implemented.”

In the release announcing the research, NATA and the National Basketball Athletic Trainers’ Association recommended five tips for keeping their student-athletes safe while playing basketball:

  1. Get a checkup before play. The groups advised parents of athletes to get a pre-participation evaluation from a medical professional, even when it’s not required.

  2. Ask about the coach. The groups recommended ensuring that a coach creates an environment where players feel comfortable to report injuries and get medical attention if necessary.

  3. Ask about emergency plans. The groups suggested asking about venue-specific emergency action plans.

  4. Get a CPR/AED-certified person at every practice and game. The groups suggested knowing where the nearest AED is, and asking if someone certified in administering it in an emergency would be present at every event (practices and games). If not, the groups recommended advocating for that equipment and those roles.

  5. Ask if there is an athletic trainer. Having athletic trainers on hand at every event can be an additional boon to emergency and cardiac care.

Source: Athletic Business

NCAA’s role in protecting student-athletes could be clouded by legal liability, among other factors (Sporting News)

By Dan Bernstein

The NCAA could end up becoming more liable to lawsuits if proposed measures aimed at protecting student-athletes pass, just one of the barriers to the organization taking a more active role in player health and safety issues.

As the NCAA introduces regulatory policies like guidelines to prevent non-traumatic deaths and improved accreditation standards for strength and conditioning coaches, it might expand its legal duty to provide care, thus making it more vulnerable to civil negligence claims, according to attorney Bob Wallace, who represents athletes and sports teams for national law firm Thompson Coburn. Two Oregon football players hospitalized in a January 2017 workout have filed such cases against the NCAA and the University of Oregon.

“When organizations or companies or industries are regulating conduct,” Wallace said, “there’s always a balancing act of how far can you go, should you go before you shift a bunch of the responsibility onto your organization.”

NCAA spokesman Christopher Radford, however, told Sporting News in a statement that “NCAA health and safety efforts are not calculated by whether there is increased legal liability but on what is in the best interests of our student-athletes.”

Fear of liability is one of several explanations offered by legal analysts, medical experts and college sports officials as to why the NCAA has not substantially addressed the issue of student-athlete fatalities. At least 27 Division I college football players have died in offseason conditioning sessions from non-traumatic causes since 2000, according to a 2017 study authored by Oklahoma head athletic trainer Scott Anderson.

Dr. Douglas Casa, who leads the Korey Stringer Institute (named after the former Minnesota Vikings player who died of heatstroke complications in 2001), blamed the NCAA’s hesitation to act on player safety issues on a philosophical disagreement between its sports science department — which is adamant the organization should have a role in health and safety issues — and the priorities of individual conferences and athletic departments, particularly as it relates to football.

“You have really stubborn people working in football (and college athletics) who don’t think in a particular way for a really long time,” Casa said, “and they don’t want to be told what to do.”

Casa’s view was echoed by several sources with direct knowledge of how conferences and member institutions think, including two who have participated in NCAA Committee on Infractions hearings, representing both the NCAA and member institutions.

Even so, Dr. Brian Hainline, chief medical officer of the NCAA’s Sports Science Institute, told SN “the needle is shifting rather rapidly” toward his organization playing a greater role in health and safety matters. He said he was aware of several NCAA investigations into schools that did not implement an NCAA-mandated independent care model, instituted in 2017.

Radford declined to elaborate on those investigations, but told SN its legislation was intended to reinforce standards of care and help schools understand their obligations.

“The NCAA does not determine the medical standard of care or second-guess the judgments exercised by health care professionals,” Radford said. “NCAA legislation does allow for limited review of whether our institutions have the structures and policies to support the health and safety of student-athletes.”

NCAA’s history with student-athlete safety issues

Anderson, the Oklahoma trainer who has become a leading advocate of student-athlete safety, said doctors realized in the late 1990s that people who carried the trait for sickle-cell anemia were at increased risk for collapsing during workouts, particularly when training in hot climates. This had led to a string of deaths in offseason conditioning sessions.

Anderson said a unified movement to screen for the trait — and educate athletic departments of its perils — began soon after, eventually leading the NCAA to require sickle-cell screening, starting in 2010.

Anderson said the screenings have prevented deaths, and he lauded the NCAA’s independent care model measure that discourages trainers from reporting directly to coaches or athletic personnel. The NCAA has also begun addressing concussions, a lightning-rod issue that has brought it criticism and put it in the crosshairs of frequent litigation.

But Anderson said it has been frustrating to watch other initiatives struggle to gain traction.

Student-athlete deaths have largely followed a pattern, wherein players are jeopardized by strenuous offseason workouts that follow sustained periods of inactivity, such as winter break or between spring and summer practices. Misunderstanding of basic medical principles has also played a role in hospitalizations.

Maryland football player Jordan McNair died in June 2018 after being asked to complete a conditioning test of 10 110-yard sprints in the team’s first organized conditioning session of the summer. His heatstroke was initially misdiagnosed, and trainers did not apply cold water immersion, a widely accepted practice to counter the effects of heat-related illness.

Those who have criticized the NCAA for not taking a more active stance as it relates to player safety say the organization could mitigate those kinds of mistakes with stronger regulation, such as the proposed best practice guidelines for preventing non-traumatic deaths.

“When you’re a 17-year-old kid or 18-year-old kid, and parents say you’re going to play in a sport and you’re provided with a scholarship, they’re basically turning that child over to make sure that kid is taken care of,” Wallace said. “And so there’s a whole bunch of things you could have a real discussion about with college athletics and the way they’re treating athletes.”

Legacy of NCAA’s stances on non-health scandals

If the NCAA was worried about how regulation might impact its legal liability before 2013, the events of that year seemingly added to its level of concern, according to ESPN college basketball analyst Jay Bilas and several legal experts.

Penn State took the NCAA to court after the latter imposed heavy sanctions on the Nittany Lions following former assistant coach Jerry Sandusky’s years of sexual abuse of children (sometimes on Penn State property). At first, the NCAA imposed a $60 million fine, four-year postseason bowl ban, scholarship reduction and vacation of all Penn State wins after 1998. It was forced to rescind many of those penalties, however, as part of a settlement with the school.

“They basically overreacted and they imposed an enormous amount of sanctions that then they had to pull back from,” said a source who has worked with the NCAA as a legal consultant. “Now they’re just hesitant to do anything.”

Since then, the NCAA has not reacted to most off-field issues, not just those relating to offseason workouts. Recent abuse cases such as former Michigan State doctor Larry Nassar’s decades-long sexual abuse of gymnasts went unpunished by the NCAA.

“I think the NCAA and those in charge within the structure, the presidents, they realize they screwed up with regard to the Penn State matter and how they went outside of the normal structure,” Bilas said. “And you can tell that because they haven’t taken any similar action in any way, shape or form on nearly identical cases that have come up afterward.”

Scandals that have involved competitive advantages or threats to amateurism, such as an FBI probe into college basketball programs paying athletes through shoe companies, have been met with more forceful responses.

“These allegations, if true, point to systematic failures that must be fixed and fixed now if we want college sports in America,” NCAA president Mark Emmert wrote of the FBI probe. “Simply put, people who engage in this kind of behavior have no place in college sports. They are an affront to all those who play by the rules.”

While Bilas does not believe the NCAA should govern any off-field issues, he said it was hypocritical for it to offer such strong public rebukes while it remained relatively quiet in instances of student-athlete deaths. The NCAA did not condemn Maryland after McNair suffered a fatal heatstroke at the team workout.

“Essentially the silence is deafening,” Bilas said. “Where’s the commission on that? Where’s the outcry on that? And there isn’t one.”

Moving forward

When Casa was a senior in high school in 1985, he suffered a heat stroke during a 10K race. He collapsed and spent several hours in a coma. He nearly died.

As a result, he has devoted his life to reforming conditioning sessions so student-athletes are no longer endangered. But given the seemingly constant wave of negative news at the collegiate level — there is an average of more than one death every offseason — it can be difficult for him to remain confident in the level of progress being made.

“You have to balance the things, right?” Casa said. “The frustration of all of these things happening, but you still need to have the motivation and the passion to continue to try to make the changes.”

Casa is optimistic the two proposed measures currently being considered by the NCAA will make a difference. But given the obstacles that have limited its role in safety matters in the past — some of which continue to weigh on the organization — it remains unclear to what extent the NCAA will play a role in managing the healthy and safety of its student-athletes.

Molly Richman, an attorney who has represented both the NCAA and schools in infractions cases, said the NCAA becoming a stronger regulatory body faces challenges that eclipse simple liability in lawsuits.

She noted member schools would need to agree to the shift in the NCAA’s philosophy and maintain respect for it, even when under investigation. She said an expanded rulebook would necessitate the NCAA hiring additional enforcement staff members. She also emphasized other areas the NCAA has traditionally monitored — like recruiting — have not been clear of wrongdoing.

But she didn’t rule out the possibility the NCAA would take that challenge on in the future.

“It’s a hard question,” Richman said. “I think it depends on the member schools, and then you have to get all the internal protocols in place for being able to enforce those rules because you don’t want to just make rules that you can’t enforce.”

Source: Sporting News

A dirty little secret vexes high school sports in Utah: Athletic trainers aren’t required for practices and games, so many schools go without. It needs to be addressed. (The Salt Lake Tribune)

There’s a dirty little secret plaguing high school sports in Utah. The fact that the plague might not be as bad here as it is in some other states shouldn’t bring much comfort.

Here’s what would bring comfort: More full-time athletic trainers hired and utilized at Utah schools.

At a conference on safety in prep sports held on Thursday in a suite at Rice-Eccles Stadium, David Perrin, Dean of the College of Health at the University of Utah, asked a significant question: “Don’t high school athletes deserve the same care as college and professional athletes in the treating and prevention of injuries?”

Anybody who answers that question with a big old negatory never pulled on the pads or laced up a hightop or a soccer or baseball cleat, or had a kid in his or her family who did so. And to those who claim that schools can’t afford it, Perrin says they should count the number of remunerated coaches on the sidelines: “They can afford it, if they will. It has to be a priority.”

Right now, it is not.

Lisa Walker, a veteran athletic trainer at Springville High School who has been on the state’s Sports Medicine Advisory Council, as well as national committees for her profession and who addressed Thursday’s conference, estimates that just more than half the high schools in Utah have “access” to an athletic trainer, but that schools that have athletic trainers on site during school days, at practices and games are “significantly fewer.”

“There is no requirement in Utah for an athletic trainer or medical personnel to be on hand,” she says. “Schools that make it a requirement should be commended. But there is no [statewide] mandate. To me, it’s disturbing.”

Doug Casa, a professor at UConn, the CEO of the Korey Stringer Institute, a national expert on exertional heat stroke, and a speaker also featured at the conference, says the problem reaches far beyond Utah: “We contacted all 21,000 high schools in America and found that only 40 percent of them had full-time athletic trainers on campus. Some schools had two or three, some had none. A third had no access to an athletic trainer, at all.”

Casa’s organization, KSI, is in the middle of a four-year outreach to enlighten and educate administrators at schools around the country about the importance of proper preparation and planning for health emergencies among student-athletes. With national and local concerns growing about concussions and heat strokes and heart events among athletes, awareness about preventing and treating such issues is on the rise.

“In the past three to five years, we’ve made more progress than the last 25 years combined,” Casa says. “We need to expand education for coaches in proper tackling techniques and in other areas and in other sports. We’re going to see good news in that space, but education needs to be mandatory for all sports.”

He adds that deaths in high school sports occur 15-20 times annually, but that lasting effects from improperly treated conditions, such as in cases of heat exhaustion and head-and-neck injuries, affect hundreds of student-athletes.

“We’re fighting to have the right protocols in place.” he says.

In 70 percent of the cases where prep athletes died over the past year, there was no athletic trainer present.

Walker, Perrin and Casa are all trying to limit, prevent those tragedies.

One of the keys to change, attendant with pushing for additional athletic trainers at schools, is changing the over-the-top macho culture that persists in some athletic programs, including coaches who not only neglect to call for appropriate treatment for distressed players, but who ridicule those who struggle in training and conditioning.

“At any time, an athlete can have head, heart or heat issues,” Walker says. “It’s not just in June or July. Education is so important — for athletes, parents, coaches and administrators. Most coaches aren’t looking to do harm, but they might not know. That’s why it’s so important to have licensed athletic trainers on hand.”

She pauses.

“It always comes down to money. I’m sensitive to that. But you would never go wrong to have an athletic trainer at each school protecting the lives of the kids. Prevention is better than having to deal with a tragedy.”

Walker concurs with Casa that progress in policy-making is rising — for instance, a 14-day-heat-acclimation period is now required for prep sports in Utah, eliminating so-called hell weeks, in which back-to-back-to-back-to-back two-a-day practices are implemented.

“Some would say, ‘Ah, you’re making the kids weak,’” Walker says. “My response is, ‘No, we’re preserving their health for today and the future.’”

A state law on concussions requires a plan and protocol for treating a high school athlete suspected of suffering one, approved by a parent.

“Any athlete thought to have had a concussion must be evaluated by a health-care professional specifically trained in concussion in the last three years,” she says. “That suspicion can come from a coach, a parent, a player.”

It should come from an athletic trainer, paid to be present at the school.

“We encourage schools to provide the best medical care they can for their students and their school community,” says Jon Oglesby, assistant director of the UHSAA. ”We have trainers at our championships.”

But making athletic trainers comprehensively mandatory would have to come from the State Legislature.

In Utah, all coaches must be current in first-aid and CPR, among other certifications, and some schools have physicians who volunteer their services at games, but that’s not enough. Immediate treatment should be available on campus throughout the day — at practices, games, even for P.E. classes.

That’s a conclusion that everyone — those at Thursday’s conference, coaches, parents and especially the athletes themselves — should agree with and find comfort in.

Source: The Salt Lake Tribune

Preventing Student Athlete Injury or Sudden Death – Interview with Dr. Douglas Casa (Principal Matters)

Dr. Douglas Casa began his study of student athletic safety in 1985 when he suffered an exertional heat stroke while running a 10K race.

As he explains, “I was fortunate to receive amazing care on-site from the athletic trainer; the EMT’s in the ambulance; and at the hospital from the emergency room physicians and nurses. I only survived because of the exceptional care I received. I was just 16 years old at the time, but I have been driven by this experience since that day.”

Whether you a leading an elementary school or high school, school activities and athletics play such an important role in the lives of your students. These programs also contribute to the overall culture and climate of your school community. As positive as these opportunities can be, it is equally important that best-practices are in place for activities, practices, and games. This includes knowing ahead of time how you or your staff will handle emergency situations.

Meet Dr. Doug Casa

Dr. Douglas Casa is a Professor at the University of Connecticut and the Chief Executive Officer for the Korey Stringer Institute.Additionally, he is the editor of a book titled: Preventing Sudden Death in Sport and Physical Activity (2nd edition, 2017), published by Jones & Bartlett in cooperation with the American College of Sports Medicine. His new book titled Sports and Physical Activity in the heat: Maximizing Performance and Safety will be published by Springer soon.

The Korey Stringer Institute

In August 2001, Korey Stringer, an All-Pro offensive tackle for the Minnesota Vikings of the NFL, died from exertional heat stroke. In April 2010, Kelci Stringer (Korey’s widow), James Gould (Korey’s agent), and the NFL asked Dr. Casa to develop and run the Korey Stringer Institute (KSI) at the University of Connecticut. The mission of the KSI is to provide research, education, advocacy, and consultation, to maximize performance, optimize safety, and prevent sudden death for the athlete, warfighter, and laborer.

For the past 18 years, Dr. Casa has worked toward his goals at the Department of Kinesiology, College of Agriculture, Health, and Natural Resources, University of Connecticut. You can read his entire bio here.

Interview Takeaways

In this podcast interview, Dr. Casa explains several important ways schools can be prepared with sound prevention policies and procedures:

  1. Find out where you state ranks in comparison to other states in the rubric provided for KSI on safety and prevention. (See KSI’s State Rankings page here.)
  2. Discover best practices for the four H’s. (Explore KSI’s website under the tab, Emergency Conditions for information on):
      • Heart
      • Heat
      • Head injuries
      • Hemoglobin, sickle-cell trait
  3. Explore affordable and practical ways to be prepared for heat-related incidents.
  4. Be prepared with written emergency plans for multiple settings on and off campus where students practice or perform.
  5. Understand the sickle-cell trait tendencies so that student athletes are appropriately rested and treated.

Let’s Wrap This Up

Dr. Casa also explains how his own story of heat stroke has come full-circle after more than 30-years in a compelling and surprising story he tells at the end this interview. Take time to listen and share this episode with others in your schools or communities who want best practices for keeping activities safe and healthy for students.

Now It’s Your Turn

What are ways you can evaluate your own school or district policies and practices in light of the KSI’s recommendations for best-practices? Do you have emergency plans for practice or competition locations? Study KSI’s state rankings and see where where your policies or procedures may need revisiting.

Source: Principal Matters

NCAA considering guidelines to help prevent offseason workout deaths (Sporting News)

The document outlines how schools should acclimate student-athletes into workouts following low-activity periods, which carry greater risk of injury or death because players have not yet adjusted to strenuous drills. It would also discourage the use of intensive workouts as a form of punishment, and establish how to properly diagnose and treat heatstroke.

Fourteen medical organizations, including the National Athletic Trainers’ Association and the Korey Stringer Institute — which strives to prevent sudden death among athletes at all levels — are reviewing the proposal and suggesting amendments. Brian Hainline, chief medical officer of the NCAA’s Sports Science Institute, said roughly half the organizations involved in the process have approved it, and the rest are expected to deliver formal reviews by Jan. 31. Hainline said he expects the document will be officially enacted and published by late spring.

“It’s a huge leap forward,” Hainline told SN, “because frankly, and we state this in the document, the vast majority of these non-traumatic catastrophic deaths and injuries are preventable.”

According to a 2017 study by University of Oklahoma head athletic trainer Scott Anderson published in the Journal of Athletic Training, 27 Division I athletes — all football players — have died from non-traumatic causes since 2000. That number does not include Maryland football player Jordan McNair, who died in June following a May 29 workout.

Still, it’s unclear how the best practices would be enforced, or whether the NCAA would eventually penalize institutions that don’t abide by the guidelines.

“Hopefully it’ll spur some dialogue and attention and cause some people to look at their programs,” Anderson said. “And you know I hear all the time, ‘The NCAA, all that is is a guideline. It has no teeth. There’s no punishment in there.’ And I understand that. But I also understand the power of a guideline.

“It’s not a law or a bylaw or legislation or anything else like that, but there’s a standard of care, and medically we violate that at our own peril. We’ve had to elevate our standard of care, our standard of how we train people. There needs to be absolutely some level of accountability and transparency.”

There was little public response from the NCAA when McNair died from heatstroke, eight months before initial review of the NCAA’s best practices guidelines. McNair’s medical treatment was marred by some of the same shortcomings that have contributed to the non-traumatic deaths of other student-athletes over the past two decades. The NCAA’s best practices proposal offers ways to avoid those mistakes.

The workout in which McNair suffered the heatstroke was the team’s first conditioning session of the summer, according to records obtained by Maryland student newspaper The Diamondback. Rather than being gradually acclimated to camp, McNair, a rising sophomore, was asked to complete a conditioning test of 10 110-yard sprints. He showed signs of exhaustion midway through the test and struggled to complete the drill, according to an independent reportcompleted by private investigative firm Walters Inc.

Maryland’s trainers then failed to meet basic protocol for diagnosing and treating heatstroke, not applying cold water immersion therapy to McNair, according to the same report. Cold water immersion is known to help patients recover from heatstroke when applied right away, according to Community Healthcare System athletic trainer John Doherty, who advises trainers in the Midwest how to respond to emergencies.

“It’s a very simple step that I work with my athletic trainers both at the collegiate and high school level constantly,” Doherty said. “I’m always reminding them that especially when there’s hot weather around, how valuable and necessary the cold water immersion stuff is because it is such a simple step and its success rate is to my knowledge 100 percent.”

After Maryland accepted “legal and moral responsibility” for McNair’s death during an August news conference, an NCAA spokeswoman told The Washington Post the university had “offered steps to ensure this does not happen again.”

At that point, however, DJ Durkin was still the Terrapins’ football coach, and assistant athletic director of athletic training Steve Nordwall and head football trainer Wes Robinson had not yet been dismissed. An independent investigationinto the football program’s culture, which found frequent instances of verbal abuse from coaches, would not conclude for another two-plus months.

When contacted for an update on Maryland’s plans to prevent future deaths, a school spokeswoman linked SN to a page listing corrective measures, saying 17 of 20 changes recommended by Walters Inc. had been completed. (Those recommendations can be found on page 67 of the below document).

The lack of action from the NCAA regarding McNair’s death consequently led critics to point out the organization’s refusal to weigh in on player safety issues while openly investigating and disciplining schools for competitive-balance violations, like paying college basketball players.

“Essentially the silence is deafening,” ESPN college basketball analyst Jay Bilas told SN. “It’s an odd feeling to see the NCAA sort of act in one fashion with regard to amateurism, and then with health and safety of athletes there’s not the same sense of urgency.”

An NCAA spokesman said the best practices currently being reviewed are the result of an NCAA-hosted information-gathering summit in 2016. That said, the document uses recommendations from a 2012 inter-association task force — composed of leading organizations in the sports medicine industry — that met independent of the NCAA and presented its findings in hopes of being formally adopted by the organization.

Hainline — who wasn’t affiliated with the NCAA at the time the 2012 task force presented its findings — said he felt the organization has moved at an appropriate pace in putting the document together. He cited required input from people throughout the college landscape, including athletic departments and school presidents who make up the board of governors.

Korey Stringer Institute head Dr. Douglas Casa, though, said better cooperation at all levels of the NCAA, particularly from football coaches, could have facilitated change sooner.

“If (the NCAA) had endorsed that back in 2012, there’s a really good chance the deaths that have happened since 2012 would have never happened,” Casa said. “Some of the things we had written were simple things that would have required modifications to prevent these deaths for happening. You know, Jordan McNair is the perfect example because it was extremely simple solutions to save Jordan’s life.”

Hainline hopes by publishing these guidelines, the NCAA can begin taking a more active stance on student-athlete health and safety. And while he and Casa both feel the best practices now being weighed are a sign of progress for improving student-athlete safety, the impact of that document will likely hinge on the receptiveness of the college sports community.

A high-ranking conference official with direct knowledge of how institutions view the NCAA’s place on this issue told SN it could prove difficult for the NCAA or conference leadership to regulate workouts. The official said schools are fiercely independent and bristle at attempts to manage their practices. Most do follow proper protocol already, the official added.

“(The NCAA and conferences) are not in the trenches, we’re not there on a daily basis,” the official said. “Now could we or should we be? That’s a philosophical question, one we’re not built for today.

“Historically, institutions have a strong desire to have their autonomy when it comes to how they spend their money, their academic integrity … and their medical training.”

To that end, Hainline emphasized his belief in a “philosophical shift” from the traditional model of self-regulating institutions to one where the NCAA provides oversight on health and safety matters — potentially even punishing schools unwilling or incapable of following along.

“I believe there should be consequences. I believe the membership and board of governors are moving in that direction,” Hainline said. “The needle is shifting. … I would say for an organization like (the NCAA), the needle is shifting rather rapidly. Others can say it’s 100 years too slow.”

Source: Sporting News

National Winter Sports Traumatic Brain Injury (TBI) Awareness Month

Brad Endres, MS, ATC, CSCS

Assistant Director of Sport Safety, Korey Stringer Institute

The new year is upon us, and with the changing of the calendar comes the increased participation in our beloved winter sports. Fittingly, January is National Winter Sports Traumatic Brain Injury (TBI) Awareness Month, so before you dust off the skates or head up the ski-lift, here is a breakdown of what you need to know to stay safe out on the slopes or in the rink.

What is a traumatic brain injury (TBI)?

The types of traumatic brain injuries include sport-related concussion (SRC), diffuse brain injury, second impact syndrome, subdural hematoma, and epidural hematoma.  Although cerebral concussions rarely cause death, they can be the starting point for other deadly brain injuries.

 

How often does TBI occur?

Between 1.6 million-3.8 million TBIs are seen in sports each year in the United States. Athletes under the age of 15 represent the majority of TBIs. Also, in every age group males show a higher rate of TBIs than females.

 

What is a sport-related concussion?

According to the 5th International Conference on Concussion in Sport held in Berlin, October 2016, a SRC is defined as a TBI induced by biomechanical forces. Several common features that may be utilized in clinically defining the nature of a concussive head injury include:

  • SRC may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head.
  • SRC typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, signs and symptoms evolve over a number of minutes to hours.
  • SRC may result in neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.
  • SRC results in a range of clinical signs and symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive features typically follows a sequential course. However, in some cases symptoms may be prolonged.

 

What are the signs and symptoms of a SRC?

The suspected diagnosis of SRC can include one or more of the following:

  1. Mechanism of Injury (eg, direct blow to the head)
  2. Physical signs (eg, loss of consciousness, memory loss, neurological deficit)
  3. Balance impairment (eg, unsteady gait)
  4. Behavioral changes (eg, irritability)
  5. Cognitive impairment (eg, slowed reaction times)
  6. Sleep/wake disturbance (eg, sleepiness, drowsiness)
  7. Signs and Symptoms including the following:
Signs Symptoms
  • Disorientation, confusion
  • Retrograde/anterograde amnesia
  • Loss of consciousness
  • Automatism
  • Unequal pupil size
  • Combativeness
  • Slowness to answer questions
  • Loss of balance
  • Atypical behavior/personality changes
  • Vacant stare
  • Nystagmus
  • Headache
  • Nausea
  • Balance issues/dizziness
  • Tinnitus (ringing in the ears)
  • Diplopia (double vision)
  • Blurred vision
  • Trouble sleeping
  • Trouble concentrating
  • Memory issues
  • Irritability, sadness,
  • Sensitivity to light or noise

 

What to do if a TBI / SRC is suspected?

Any person suspected of a SRC should be removed from the mountain or event area immediately and evaluated by a licensed healthcare professional who is trained in the evaluation and management of concussions. The injured person suspected of a SRC should not return to activity on the same day as injury. Finally, continued monitoring of an athlete evaluated of having a SRC is necessary in order to observe any deterioration of physical or mental status (which warrants transport to local healthcare facility).

 

How do you treat an individual with a TBI / SRC?

After being evaluated by a health professional, treatment and management of a TBI/SRC includes:

  • Physical and Cognitive Rest: Physical and Cognitive activities that result in an increase in symptoms should be avoided during the acute phase of concussion treatment
  • Medications that mask the symptoms of a concussion (NSAIDS, Aspirin, stimulants, and antidepressant) should be avoided, especially in the acute phase of the injury.
  • The use of acetaminophen (Tylenol) may be considered in treating symptoms such as headache but should be used after the acute phase of the injury
  • Athletes sustaining a concussion should have a follow-up appointment with their general practitioner to evaluate the mechanism of injury, the course of symptoms, and any previous history of concussive injuries.
  • Return-to-play following a concussion should follow a graded return-to-play protocol. This protocol should consist of 5-7 stages and take 5-7 days to complete (if there is no recurrence of symptoms). The graded return to play protocol should begin once the athlete has a cessation of symptoms for at least 24 hours. An athlete must be prohibited from returning to activity if they are still experiencing symptoms.
  • The goal of the return to play protocol is to progressively increase the duration and intensity of exercise to ensure that there is no return of symptoms with physical exertion. See the table below to see an example of a 6-stage return-to-play protocol.
Rehabilitation Stage Functional Exercise at each Stage of Rehabilitation
1.  No activity Complete physical and cognitive rest
2.  Light aerobic exercise Walking, swimming, or stationary cycling keeping intensity <70%
No resistance training
3.  Sport specific exercise Skating skills in ice hockey, slide board for skiing, general agility drills
No head impact activity
4.  Non-contact training drills Progression to more complex training drills (eg: passing drills in ice hockey, bunny slopes for skiing/snowboarding)
May begin progressive resistance training
5.  Full-contact practice Participate in normal training activities
6.  Return to play Normal game play or event competition

 

How do I prevent a TBI / SRC?

Based on the most updated consensus statement created by a committee of sports medicine professionals at the 5th International Conference on Concussion in Sport, the following steps were recommended for TBI prevention:

  • Protective Equipment: There is sufficient evidence in terms of reduction of overall head injury in skiing/snowboarding to support strong recommendations and policy to mandate helmet use in skiing/snowboarding. The evidence for mouthguard use in preventing SRC is mixed, but suggests a positive trend towards a protective effect in collision sports (such as hockey).
  • Rule Change/Risk Compensation: The strongest and most consistent evidence evaluating policy is related to body checking in youth ice hockey (ie, disallowing body checking under age 13), which demonstrates a consistent protective effect in reducing the risk of SRC.
  • Aggression/Violence: Appropriate competition and the aggressive nature of some sports is not discouraged, however unnecessary violence or other aspects should be evaluated based on the merit they provide in the sport.
  • Education: The ability to detect and deal with a TBI is enhanced when everyone on the slope or ice is looking out for the safety of the athletes.  Education should include the athletes themselves, coaches, administrators, and parents.  It should cover basic tools for recognition, what to do if they suspect a concussion, and the process of treatment and returning to participation.

What are the risk factors for SRC?

  • Previous concussions: A previous history of a concussion increases the risk of sustaining another concussion on the order of 2-5.8 times greater risk
  • Number, severity and duration of symptoms: Evidence has shown that those who report a greater number of symptoms, or report a greater severity of symptoms or duration, may experience a longer recovery than those who experience less severe symptoms.
  • Sex: Research has shown that females experience a higher incidence of concussion in addition to reporting a increased number/severity/duration of symptoms, and prolonged recovery.
  • Age: Young athletes may experience a prolonged recovery from a concussion and may be due to the differences in the developing brain of a child/adolescent compared to that of an adult brain
  • Sport, position, and style of play: Depending on the sport, position, and the athlete’s style of play increases the risk of concussion. In sports where there is player-to-player contact, the risk of concussion increases. The table below outlines the incidence the risk of concussion for various sport.
  • Mood Disorders: Mood disorders such as depression, anxiety, and irritability may complicate both the diagnosis and management of a concussion
  • Learning disabilities and attention disorders: Learning disabilities such as ADD/ADHD or others that result in some form of cognitive dysfunction can complicate the management of a concussion and may lead to a longer recovery time post-concussion

So bundle up, have fun, and most importantly stay safe this Winter! For further information, check out the TBI page at the Korey Stringer Institute’s website at https://ksi.uconn.edu/emergency-conditions/traumatic-brain-injury/. The 5th International Conference on Concussion in Sport publication can be found at https://bjsm.bmj.com/content/51/11/837.full.pdf.

30 NCAA Football Players Have Died During Workouts Since 2000, HBO Reveals (American Council on Science and Health)

When writing about this topic three weeks ago, our focus was mostly on the failure of high schools to protect student-athletes from potentially-fatal heat stroke.

Little did we know what the big boys – for a much longer time – were failing to do as well.

With a key preventive measure being so simple – the availability of a tub full of ice water – it defies all logic that this simple step isn’t being taken everywhere strenuous workouts are being held.

But now comes the revelation that NCAA football players are being worked so hard during practice that they’ve been regularly dying of heat stroke since the beginning of this century.

This week, the HBO newsmagazine show “Real Sports with Bryant Gumbel” reported that “since the year 2000, 30 players have died as a result of college football workouts.” The cause: heat stroke, which is completely preventable if college officials overseeing grueling practices – usually athletic trainers – can identify a stricken player’s physical distress while it’s happening and immediately have him immersed in a nearby ice bath.

Yes. Thirty dead players in 18 years, or nearly two every year.

And inevitably, when grieving parents ask what could have been done to prevent such a senseless tragedy, they are always – always, 100 percent of the time – presented with this overlooked remedy. A solution so simple, in fact, that is must make their loss even more painful.

“A tub, ice and water would have saved their child’s life. That simple,” states Dr. Douglas Casa, who is “among the leading experts of sudden death in sports,” according to correspondent Jon Frankel. “It will save their life, every time.”

And yet, having icing tubs available during practice is not mandated by the NCAA.

Even more frustrating, HBO‘s Frankel revealed that Dr. Casa, who leads the Korey Stringer Institute, a leading organization on heat stroke and its link to player fatalities, has collaborated with colleagues in drafting a list of specific recommendations that detail how these type of fatalities can be prevented.

The document, “The Inter-Association Task Force for Preventing Sudden Death in Collegiate Conditioning Sessions: Best Practices Recommendations,” was sent in 2012 to the NCAA, which has failed to enact the practices, in their entirety or even partially. The organization said the changes would be too difficult for member colleges and universities to implement. (photo of Dr. Casa courtesy: Korey Stringer Institute)

In the meantime, college football players continue to die from heat stroke. Most recently it was Jordan McNair, a 19-year-old at the University of Maryland, whose core body temperature soared to 106 degrees during a May 29 workout while undergoing intensive conditioning that included repeated 100-yard sprints. The freshman was not placed in an ice bath while awaiting EMTs and died 15 days later.

In addition, there’s this: “The rise in the deaths during workouts has corresponded with another sharp rise,” Frankel noted, “the rise in the prominence and pay of strength and conditioning coaches.” Men in these positions have been given ever-greater influence to push football players to their physical limits, and they’ve been doing just that.

But Frankel tells us that there’s one substantial shortcoming with their professional education in this field: strength and conditioning coaches can get certified without learning anything about player health. All they have to do is pass a 13-hour course – one that includes no safety training at all.

“The deaths, at this point in time, absolutely it’s predictable. They’re going to occur. It’s disturbing. It’s really inexcusable,” said Scott Anderson, the longtime athletic trainer for the University of Oklahoma. “Without question, the role of the strength and conditioning coaches has grown over time. There should be some accountability that comes with that.”

In the wake of these 30 deaths, the NCAA has yet to mandate any safety or medical training for strength and conditioning coaches, HBO reports. And not one has ever been disciplined as a result of a player fatality during their watch.

Source: American Council on Science and Health