Researching Heatstroke In Athletes (NPR)

The death of a University of Maryland player is among a number of training deaths in college football recently. Melissa Block speaks with Douglas Casa who has researched the causes.


In June, a 19-year-old freshman on the University of Maryland football team died in a hospital of heatstroke. Jordan McNair had collapsed two weeks earlier after running long sprints during training. His body temperature when he arrived at the hospital was 106 degrees. The university has opened an investigation, and head coach D.J. Durkin has been put on administrative leave. Many blame an abusive, toxic coaching culture at the university for McNair’s death. And it’s not just Maryland. According to the National Center for Catastrophic Sport Injury Research, a dozen college football players in addition to Jordan McNair have died just from heatstroke since 1995. That figure is higher if you include things like sudden cardiac arrest and asthma attacks. Douglas Casa studies heat illness and sudden death in sport at the Korey Stringer Institute at the University of Connecticut. And he joins me now. Mr. Casa, welcome to the program.

DOUGLAS CASA: Yeah. Thank you very much for having me.

BLOCK: And what do you make of the case of Jordan McNair? This was an offseason practice. This was not during a game.

CASA: Yeah. That is correct. It is during a collegiate conditioning session, which is really the place where we’re having the most problems right now dealing with sudden death in sport.

BLOCK: According to reports that have come out, when Jordan McNair had trouble standing after these long sprints, one of the trainers reportedly yelled, drag his ass across the field. Is that – does that speak to a culture that you find very common in college football?

CASA: Thank God that’s not common. But, you know, did that potentially delay the appropriate care? It may have. And we know in the world of exertional heatstroke that when you cool somebody down to under 104 degrees within 30 minutes, survivability is 100 percent in all the people that have ever been studied. So it’s a complete shame when you don’t have the correct, you know, treatment being done for the person on the field at that time.

BLOCK: The institute where you work is named for Korey Stringer. He’s the NFL lineman. He died of heatstroke in 2001 in a workout. And since then, as I understand it, there has been no NFL player that’s died of heatstroke. So what is the NFL doing that college football apparently isn’t?

CASA: There’s probably a few things to consider that I would say are things to consider to model. One is the NFL, after the death of Korey Stringer, thankfully, made sure that the best practices were being utilized by all 32 teams with the prevention, recognition and treatment of exertional heatstroke. So that’s obviously helpful. Second, the players, in conjunction with the NFL, have developed appropriate policies to make sure that they stay safe. So in a sense, the players have rights in the NFL. And the players have no voice and no rights in college football. College conditioning coaches and college football coaches can literally do anything they want, you know, during a conditioning session. But in pro football, the players and the teams, you know, work together in unison, I think, a lot better.

BLOCK: I’ve seen the term used in terms of how these workouts are conducted at the college level – this term irrational intensity workouts – in other words, pushing people well past the point of anything being helpful or useful in their training.

CASA: That’s correct. Back in 2012, we convened a task force. And all the top sports medicine organizations in the country attended and endorsed the document that was called “Preventing Sudden Death In Collegiate Conditioning Sessions.” But the NCAA did not endorse that document. If they had endorsed it, I’m sure we would not be having this conversation right now. And we wouldn’t have had a lot of those deaths that we’ve had in the last six years. But they have not done enough to make collegiate conditioning sessions of more a controlled environment. Right now, it’s the Wild West.

BLOCK: I’m thinking about a column that Sally Jenkins wrote in The Washington Post in which she essentially accused college coaches of working these kids to death on the field. Do you agree?

CASA: Yeah. In lot of cases, that’s true because you’re doing workouts that are not intuitive for what you need at that time. I’ll give you a great example. In 2013, the University of Iowa – in the first day back in January when they were doing a workout, they had the football team do 100 squats. And they had 13 people hospitalized within a day. Those players could have done 100 squats if they had trained for it properly over a few weeks but not on the first day back. So that happens across the country all the time. But the NCAA needs to make the big steps to make some big policy changes so that we can protect all of these college athletes in football and in every sport.

BLOCK: That’s Douglas Casa. He’s CEO of the Korey Stringer Institute at the University of Connecticut. Thanks so much for speaking with us.

CASA: Thank you – pleasure to be on.

Source: NPR

Prehistoric college football coaches are killing players. It’s past time to stop them (Washington Post)

“They get to dictate these things, and we get to keep burying athletes until we make definitive changes to the culture,” said Dr. Douglas Casa, a kinesiologist who serves as CEO of the Korey Stringer Institute at the University of Connecticut.

Since 2000, there have been 40 athlete fatalities in conditioning sessions in multiple sports across the NCAA, yet not a single death on the field, according to Casa. This despite the fact that schools have all the education and tools to prevent it: Heatstroke exertion is 100-percent survivable with a thermometer and some ice. The NFL has eliminated it altogether and to its credit continues to consult with the Stringer Institute on research and best practices to prevent sudden deaths. The NCAA, on the other hand, has remained lethally antiquated. Unlike NFL players, collegians have “no voice, and no rights,” Casa pointed out. McNair was forced to run 10 sprints of 110 yards, until his body temperature was 106. It was a nonsensical workout that had zero football relevance and demonstrated nothing about his character except that he was willing to work himself into a coma for fear of punishment from an all-powerful authority figure. “It’s a totally unregulated environment,” Casa said.

New Jersey boasts nation’s top health and safety policies for student-athletes (USA Today)

As student-athletes across New Jersey resume practice for fall sports this week, they can do so with confidence knowing the statewide athletic association of which their high schools are a member boasts the country’s most comprehensive health and safety policies.

The New Jersey State Interscholastic Athletic Association is the best in the nation in the area of managing injury risk to high school student-athletes, according to the Korey Stringer Institute’s second annual national ranking of statewide athletic associations.

Korey Stringer Institute researchers found many states are not fully implementing safety guidelines intended to protect student-athletes from heat stroke, sudden cardiac arrest and other potentially life-threatening conditions that may be prevented with proper policies. The institute, housed at the University of Connecticut, ranked states according to the extent to which they met a series of evidence-based best practice guidelines.

The NJSIAA, which has long been a leader in implementing and adopting safety protocols, improved its ranking from fourth to first out of 51 statewide athletic associations, according to the institute’s 2018 High School Sports Safety Policy Rankings.

New Jersey wrested the top spot from North Carolina, whose state university runs the National Center for Catastrophic Sports Injury Research. Last year, the Korey Stringer Institute determined the North Carolina High School Athletic Association had the most comprehensive health and safety polices in place for secondary school athletics.

Among the statewide athletic associations governing the nation’s 7.8 million student-athletes, North Carolina was ranked second this year, followed by Massachusetts (third), Kentucky (fourth) and Florida (fifth).

“We are very encouraged by the positive changes that have occurred across the nation,” said Douglas Casa, CEO of the Korey Stringer Institute and a professor of Kinesiology at the University of Connecticut who is one of the nation’s foremost authorities on the prevention of exertional heat stroke and other serious injury in sport. “However, we need to continue to be vigilant. We are fully committed to working with individual states on adopting these important guidelines.”

Source: USA Today

D.J. Durkin’s Program Under Scrutiny as Maryland Parts Ways With Strength Coach (The New York Times)

The president of the University of Maryland made a startling admission Tuesday, saying basic medical procedures had not been followed when a football player collapsed in the heat during a conditioning workout in May and died two weeks later.

The president, Wallace D. Loh, said that Maryland accepted “legal and moral responsibility” for the death of the player, Jordan McNair, a 19-year-old offensive lineman.

D.J. Durkin, Maryland’s head coach, remained on administrative leave in the wake of a blistering report by ESPN last week that he had created a verbally abusive and humiliating atmosphere at the university’s football program.

But the university said the team’s strength and conditioning coach, Rick Court, was no longer working there. Hours after the university’s statement on Tuesday, Court said on Twitter that he had resigned a day earlier and posted what he said was his resignation letter.

Loh said that a preliminary investigation faulted the training staff, not the coaching staff, for failing to treat McNair properly. But he said he had appointed a four-person commission to investigate the practices and culture of the football program.
McNair’s death has forced the insular, hypermasculine and scandal-ridden world of college football to reckon with itself once again about whether it is sufficiently protecting its players. Universities and the N.C.A.A. have come under criticism for not sufficiently monitoring conditioning workouts, especially in the off-season.

The university acknowledged that McNair’s temperature and other vital signs were not taken and that he was not immersed in a cooling bath — standard procedures — after being overcome while running sprints during the May workout.

“The athletic training staff, not the coaching staff — they basically misdiagnosed the situation,” Loh said at a news conference at the university in College Park, Md.

Earlier in the day, Loh and Damon Evans, Maryland’s athletic director, said they had visited McNair’s parents in Baltimore and apologized to them. Loh repeated to reporters what he said he told McNair’s parents: “The university accepts legal and moral responsibility for the mistakes that our training staff made on that fateful workout day of May 29, which of course led subsequently to his death on June 13.”

Loh and Evans said they also took seriously the accusations of intimidation and denigration of players by Durkin and the training staff described in the recent ESPN article and other news reports.

“We will not tolerate any behavior from any employee within Maryland athletics that is detrimental to the mental or physical well-being of our student-athletes,” Evans said.

Durkin, 40, has generally been portrayed as a stock football character, one who was fiercely intense but not possessing a reckless ardor.

When he was an assistant at Stanford, from 2007 to 2009, Durkin once engaged in what has been described as a ferocious game of one-on-one basketball with the equally intense head coach at the time, Jim Harbaugh.

The game is said to have lasted 90 minutes and, in Durkin’s telling on a radio show, “there was no fouls being called and there was a lot of blood on the court.”

Durkin also worked under Harbaugh as a defensive coordinator at Michigan in 2015. In a profile in The New York Times that season, a Stanford coach who had worked with both men used a pet phrase of Harbaugh’s to describe Durkin’s approach to football: “With enthusiasm unknown to mankind.”

When Durkin was hired at age 37 to become head coach at Maryland for the 2016 season, he seemed to have an impeccable résumé as a highly-regarded recruiter who had been an assistant not only under Harbaugh, but also under Urban Meyer at Florida. He had learned from the best and would now have a chance to test himself against the best in the Big 10 Conference, annually facing Harbaugh at Michigan and Meyer, now at Ohio State, along with Penn State, trying to rebuild a program that had enjoyed only sporadic success.

Harbaugh spoke extravagantly of Durkin’s driven nature on his weekly radio show in 2016, saying, “I always get a smile when I think of D.J. because I think of the foam coming out of the side of his mouth, snot bubbles percolating when he’s really intense. He’s a great competitor.”

The question is whether that passion strayed beyond the limits of propriety as Maryland lost a majority of its games under Durkin.

The ESPN report described a football culture of belittlement and intimidation, according to current and former players and staff members, who said that coaches and trainers commonly embarrassed and shamed players. Two former Maryland players spoke on the record; other accusing sources in the story were anonymous.

Among the accusations in the ESPN article: An offensive lineman considered overweight was forced to eat candy bars in front of his teammates as they worked out. Another player was forced to eat to the point of vomiting. Players’ masculinity was mocked when they were unable to complete a workout or lift a weight, and one player was belittled after passing out.

ESPN reported that on the afternoon of May 29, McNair collapsed while running 10 110-yard sprints; that nearly an hour passed before a call was made to 911 (the university disputes this); and that McNair’s body temperate was 106 degrees when he arrived at a hospital.

William H. Murphy Jr., a lawyer for the McNair family, has said that the cause of death, not yet confirmed, was heat stroke. He has called for Durkin and others to be fired, calling the behavior of the coach and other staff members “reprehensible.”

Since 2000, 31 N.C.A.A. football players have died during off-season or preseason workouts from heat stroke, cardiac issues, asthma and other factors, according to Scott Anderson, the head athletic trainer at the University of Oklahoma, who keeps a database of athletic fatalities.

Since Jan. 1, 2013, there have been eight known severe cases of heat stroke involving N.C.A.A. football players, with three deaths, Anderson said in an email message. He said he could find no similar “cluster” of deaths until decades earlier, in 1962-63.

Douglas Casa, the chief executive of the Korey Stringer Institute at the University of Connecticut, named for a Minnesota Vikings tackle who died of heat stroke in 2001, said heat stroke is readily treatable with “100 percent survivability.”

“Jordan would have survived if he was treated properly,” Casa said of McNair, the Maryland player.

The onset of heat stroke is almost always preventable, too, Casa said, criticizing what he described as “crazy, ridiculous workouts” that players are subjected to, particularly in the off-season when training sessions are not always vigorously monitored and athletes can be subjected to “needless jeopardy.”

The N.C.A.A. has been slow to adopt recommendations set forth in 2012 by sports medicine experts seeking to prevent sudden death in collegiate conditioning sessions, Casa said. “That’s where the greatest risk is because it’s the Wild Wild West,” he said. “There’s no oversight. You have a coming together of many unfortunate factors that cause these kind of catastrophic injuries.”

As Durkin awaits his fate as Maryland’s football coach, he still has his supporters. Will Muschamp, the South Carolina coach who previously promoted Durkin to defensive coordinator at Florida, told reporters, “I find it hard to believe some of the things that I read” in the ESPN article, and he criticized the use of anonymous sources.

Ben Muth, a former All-Pac-10 lineman at Stanford while Durkin coached there, wrote on Twitter, “I have a lot of respect for him as a person and a coach. I never doubted that he really cared about us as players and people, and wanted the best for us.”

In another tweet, Muth wrote, “I could go to any school in the country and find 3-12 kids to bitch about the culture/abuse. And another 2-20 people that just graduated, and another ex-staffer or 2. The only difference at Maryland is that a kid passed away. Durkin wasn’t even at that workout I imagine.”

Muth’s comment in support of Durkin might signal — correctly, if unintentionally — that football’s culture will persist unabated even after the tragedy at Maryland.

“This would seem to be a moment of necessary introspection for the sport,” David Andrews, a sports sociologist at Maryland, said in an email, “but as with the gun violence issue in this country more generally, my feeling is that Jordan McNair’s senseless death will be a brief point of discussion, largely forgotten by the general public once the football season/industry gets in full swing.”

Source: The New York Times

Experts say Maryland may not have acted quickly enough to save football player (The Washington Post)

Nearly 40 minutes after a 911 call was placed, Jordan McNair arrived at Washington Adventist Hospital in Takoma Park with a body temperature of 106 degrees, according to a hospital medical report. Once admitted, the 19-year-old Maryland football player was covered with ice and cold water, a cooling method known as cold-water immersion. It took 12 minutes for his body to cool to 102 degrees, which one medical expert called “a much, much safer temperature.”

Cold-water immersion was the most effective way to treat the exertional heatstroke that McNair suffered during a team workout May 29 in College Park, but medical experts said details contained in hospital medical records and an incident report written by Prince George’s County medical responders suggest it was used far too late.

McNair never recovered, and he died June 13, an event that has rocked the program, led the school to place Coach DJ Durkin on administrative leave and prompted two external investigations.

Had football trainers and athletic staff been able to lower McNair’s temperature more quickly at the practice field, heatstroke experts interviewed by The Washington Post said, the offensive lineman likely would have survived. The experts, who are not affiliated with the University of Maryland, reviewed the details available in hospital medical records and the medical responders’ report but urged caution because the full timeline from the day has not been released and is still under investigation by the school.

“For patients with exertional heatstroke, time is of the essence,” said John Jardine, an emergency medical physician and chief medical officer of the University of Connecticut’s Korey Stringer Institute. “We know if you get a patient’s temperature down within 30 minutes, we have reported 100 percent survivability.”

Maryland officials have not discussed the events surrounding McNair’s death in detail, nor have they divulged the treatment that he received or the efforts made by staff to lower his body temperature. The afternoon’s timeline probably will serve as the crux of the school’s external investigation and a federal lawsuit planned by McNair’s family.

Maryland football player Jordan McNair, shown in this undated photograph, died in June after collapsing during a team workout. (Photo provided by McNair family attorney)

While medical experts said heatstroke is easily treatable, hospital medical records reviewed by The Post and the incident report written by medical responders suggest McNair’s temperature had not been sufficiently cooled by the time he was admitted to Washington Adventist Hospital, which is about four miles from campus.

The hospital records say McNair initially showed symptoms of heatstroke 45 minutes into the team’s workout, which began at 4:15 p.m. That would have been more than 90 minutes before McNair’s temperature was lowered to 102 degrees by hospital medical personnel. Maryland officials strongly dispute that timeline. “At no point before or during the external review has a student-athlete, athletic trainer or coach reported a seizure occurring at 5 p.m.,” the school said in a statement.

“I’m very confident in the personnel we have and the procedures we have in place,” Durkin said at Big Ten media day last month, the last time he addressed reporters before being placed on administrative leave Saturday. “And again we’re looking at those and making sure there’s anything we can do better or do differently, then we’ll be able to do that.”

Jardine has treated more than 350 exertional heatstroke patients and said every one of them survived because he used cold-water immersion to cool their body temperature within 30 minutes. That sentiment was echoed by Douglas Casa, the chief executive of the Korey Stringer Institute, which aims to prevent sudden death in sport. The institute was established in 2010 in honor of Stringer, a Minnesota Vikings offensive lineman who died of exertional heatstroke in 2001.

“If I were betting, they were not using cold-water immersion,” Casa said, stressing that all the details were not yet known and that he had no firsthand knowledge of the steps taken by Maryland personnel. “And if they did, they didn’t use it long enough to help him out, and something happened to stop the treatment.”

The first 911 call that day was made at 5:57 p.m., according to the incident report written by medical responders, and McNair arrived at the hospital at 6:36. His reported body temperature of 106 degrees indicates cold-water immersion was not used, according to medical experts contacted by The Post, and the window to ensure recovery had passed. Multiple medical experts said death by exertional heatstroke is 100 percent preventable if the patient is placed in a cold-water tub and the body temperature is cooled to 104 degrees or lower within 30 minutes of symptoms appearing.

“Everything is a little bit of speculation here, but if someone was struggling clearly at 5 o’clock, and then the ambulance didn’t arrive until 6:10 or 6:15, that’s a 70-minute stretch of time?” Casa said. “So in that 70 minutes, just to give you an idea, if they used cold-water immersion, you can get someone from 110 [degrees] to 102 in, like, 30 to 35 minutes. So he was still at 106 when he got to the hospital, and I’m saying 110 is a worst-case scenario from what I’ve seen in my career.”

Asked to comment for this story, a Maryland spokesman referred to the school’s previous statements on the day’s events but declined to answer further questions about the training staff’s response and the school’s policies regarding heatstroke prevention and care. School officials declined to specify whether cold tubs were present and operational at the practice fields the day McNair was hospitalized.

Maryland has not released details of the events of May 29 while it is participating in an external review of McNair’s death. The review is being conducted by Walters Inc., an athletic training consulting firm, and is expected to conclude around Sept. 15.

In the wake of newly reported details of McNair’s death, and accounts by The Post and ESPN of an abusive football culture in College Park, Maryland placed four staff members on administrative leave: Durkin, head strength and conditioning coach Rick Court, athletic trainer Wes Robinson and assistant athletic director of athletic training Steve Nordwall. The university has said that the workout was run by the strength and conditioning coaches, that athletic trainers were present throughout and that Durkin and his coaching staff were also on hand.

The NCAA’s sports medicine handbook includes a variety of recommendations for schools to protect athletes from heat-related illness, and Casa helped write the section related to heatstroke.

The handbook warns that “a delay in treatment can be fatal.” It advises an emergency action plan and “immediate cooling of the body with cold water immersion” and points to a recommendation issued by a National Athletic Trainers’ Association task force: “Cool first, transport second.”

That task force, composed of a nationwide panel of experts and physicians, came up with a list of recommendations and urged every organization to “have a policy, procedure or emergency plan established to address exertional heat illnesses.”

“Aggressive and immediate whole-body cooling is the key to optimizing treatment,” the task force noted, adding that cold-water immersion “should be initiated within minutes post-incident.”

Casa outlined the three key steps to treating exertional heatstroke, with the first being quickly recognizing the signs and symptoms. The two main signs are cognitive nervous system dysfunction — which can feature a number of symptoms, including combative behavior, disorientation, loss of consciousness or, as was the case with McNair, a seizure. The second sign is a rectal temperature above 104 degrees; rectal thermometers have been proved to give the most accurate body temperatures.

The second step is to use cold-water immersion to cool the body temperature to 104 degrees or lower. The third step is to cool the player’s body temperature to a safe level, then transport him to a hospital. A 2015 position statement released by NATA said that medical personnel should prepare to cool the patient and contact emergency responders once heatstroke is detected.

“Best practices are in the literature, and the team physicians and the team trainers are all licensed medical professionals in the state of Maryland, and they are obligated to follow best practices to care for the individuals that they are responsible for,” Casa said. “And cold-water immersion — cool first, transport second, rectal temperatures — they are all completely understood to be best practices, and they are in every document that has been released in the last 10 years.”

“Like I said, we don’t know all the details,” Casa added, referring to Maryland’s handling of McNair on May 29. “But it seems like all those things were not followed.”

Roman Stubbs and Rick Maese contributed to this report.

Source: The Washington Post

Cold-water immersion is ‘magic elixir’ for heatstroke — and a question in treatment of Maryland’s Jordan McNair (The Baltimore Sun)

In the University of Maryland Medical Center hospital wing where he had lain five years earlier, battling for his life, Gavin Class leaned over the bed of Jordan McNair, grasped his hand and whispered to him.

“Be strong, Jordan,” Class recalled saying in his early-June visit. “Fight every day. Be positive.”

McNair, 19, an offensive lineman for the University of Maryland football team, had by then been hospitalized at Baltimore’s Maryland Shock Trauma Center for a week. After the former McDonogh star collapsed during a late-afternoon May 29 workout, he was taken to Washington Adventist Hospital and later Shock Trauma. McNair died June 13, about a week after Class’ visit, of heatstroke.

Maryland’s timeline of the day McNair collapsed offers only a general account of what happened from the time he began “having problems recovering” to when a 911 call was placed.

But medical experts said Monday that McNair’s health could have hinged on Maryland’s adherence to medical guidelines for treating heatstroke, including cold-water immersion — a practice which doctors said likely saved Class’ life after he was stricken during a Towson University football practice in 2013.

Attorney William H. “Billy” Murphy Jr. and associate Malcolm Ruff, who are considering filing a lawsuit on behalf of McNair’s family, say the firm has corroborating evidence that suggests McNair was showing signs of exertional heatstroke as he completed a series of sprints.

When McNair was taken from the workout in College Park to nearby Washington Adventist Hospital, Ruff told The Baltimore Sun on Monday, medical records indicate his body temperature was 106 degrees, a sign of heatstroke.

Douglas Casa, CEO of the University of Connecticut’s Korey Stringer Institute, a nonprofit dedicated to preventing sudden death in sports, outlined a best-practice approach for treating possible heatstroke. The two key diagnostic criteria, he said, are central nervous system dysfunction — signs include confusion, altered consciousness and seizures — and a rectal temperature of at least 105 degrees.

If those symptoms are present, Casa said, cold-water immersion should be used.

“It’s the magic elixir,” said Casa, who said he has treated over 285 heatstrokes and studied over 2,000 such cases. In cold-water immersion, he added, body temperature can fall about a degree Fahrenheit every three minutes. “That’s the thing that’s going to allow the person to survive.”

Dr. Raj Deu, an assistant professor of orthopedic surgery at the Johns Hopkins University School of Medicine, said that the more a body is exposed to cold water, the more effective the treatment.

University officials have not said whether McNair’s treatment included cold-water immersion. Asked about that, they referred a reporter to their official timeline, which does not mention it. Ruff said Sunday that there were no ice baths present at McNair’s workout.

The fallout from McNair’s death has thrown the Terps’ program into disarray, with coach DJ Durkin and three other staff members placed on administrative leave amid reports of an abusive coaching culture. The university is awaiting the results of an external review of the protocols and procedures relating to the death of the Randallstown native. Walters Inc., a sports medicine consulting firm, is expected to conclude its investigation by Sept. 15.

According to Maryland’s timeline, the team’s practice began at 4:15 p.m. Athletic director Damon Evans has said players did a “dynamic workout” of 15 to 20 minutes of stretching before turning to 10 repetitions of 110-yard sprints.

The timeline says athletic trainers “began supporting an active recovery and providing care” when they noticed McNair having problems, but the university account does not say what time that happened. Later, the university said, he was taken to the athletic training room on a Gator utility vehicle for “further observation and continued treatment.”

Shortly before 6 p.m., according to tapes obtained through a public-records request, a 911 call was placed in which an unidentified caller described McNair as having breathing problems. McNair arrived at Washington Adventist Hospital at 6:36 p.m., according to a Prince George’s County incident report. At the hospital, Ruff said, McNair’s body temperature dropped to 102 degrees within minutes of cold-water immersion by hospital staff.

Prolonged hyperthermia can cause “large-scale” damage, Casa said. A body temperature around 105.5 degrees is a “critical threshold” for cell damage, he said, but human bodies normally can handle about a half-hour above that temperature without long-term complications.

After that time, Casa said, cells denature. This disruption of their molecular structure “obviously causes things to happen that are not optimal,” he said. Vital organs like the kidney, liver and brain can be affected.

“I would say many would die if you go up to 60 minutes [of hyperthermia],” he said.

The doctors who treated Class five years ago have said the treatment he received, including cold-water immersion, was critical to his survival.

Class went to visit McNair in the hospital in June after McNair’s family reached out to him.

For Class, the traumas of the two strapping offensive linemen seemed unbearably similar. In August 2013, Class collapsed during a Towson practice and was rushed first to the University of Maryland St. Joseph Medical Center, then to Shock Trauma with kidney failure and a dying liver. His temperature peaked at 108 degrees, and he arrived at Shock Trauma in cardiac arrest. Twice, his parents were told to brace for the worst.

As he lay comatose, awaiting surgery for a liver transplant, his mother, Danielle Class, pleaded with her son: “Keep fighting. Keep fighting. You’re strong. Don’t give up!”

In June, Class echoed those words as he stood over the bed of McNair, whose family had asked Class to come.

“They were so grateful that I took time to come [to the hospital], though in my mind, there was no option,” said Class, 25, an assistant strength and conditioning coach at Johns Hopkins. “I was there to provide hope and to help any way that I could. We talked about our faiths and how God does this to people who can handle it and how it happens for a purpose.”

“My family and I prayed for Jordan every day,” Class said. When he learned McNair had died, “I was in shock; there’s no way this should happen.”

When Class collapsed at practice, Towson trainers immediately immersed his body, neck-high, in a 300-gallon Rubbermaid tub filled with cold water that they kept on the sideline, the athletic training staff said then. They kept him in the 50-degree water for seven to 10 minutes, while coaches and trainers stirred frantically by hand.

“That time in the ice bath absolutely saved me,” Class said Monday, the day after the five-year anniversary of his own heatstroke.

Source: The Baltimore Sun

Heatstroke dangers reinforced by investigation into death of college football player (USA Today)

Minnesota Vikings Pro Bowl tackle Korey Stringer’s death at practice in 2001 led to increased awareness and education on the dangers of heatstroke during summer football conditioning.

But it hasn’t come close to eliminating the threat, according to Rebecca Stearns, chief operating officer for Korey Stringer Foundation.

“We see an average of about three deaths per year from heatstroke across all levels,” Stearns told USA TODAY Sports. “But the last five years have been really telling because we have seen a gradual increase in the number of exertional heatstroke deaths.”

The issue is in the news again this weekend. Maryland put football coach DJ Durkin on leave Saturday, a day after putting other athletic department personnel on leave as an investigation continues into the death of a football player during offseason workouts earlier this summer.

Jordan McNair, a 19-year-old offensive lineman, died on May 29, two weeks after being hospitalized following an organized team workout. The cause of death was heatstroke, according to a foundation named after the player.

Late Friday, ESPN published a story in which players and former staffers talked atmosphere of “fear and humiliation” that included verbal abuse at Maryland under Durkin. Specifically cited as helping create that culture was strength and conditioning coach Rick Court.

According to the Mayo Clinic, heatstroke is caused by the body overheating, “usually as a result of prolonged exposure, or physical exertion, in high temperatures.”

The Mayo Clinic refers to it as “the most serious form of heat injury.”  It occurs if a body’s temperature rises to 104 degrees or higher. Untreated heatstroke can quickly damage a person’s brain, heart, kidneys and muscles.

Football players are vulnerable because they practice, often wearing helmets, in the August heat. Besides, McNair, defensive back Darius Minor of Maine also collapsed and died at a workout, and a state of Washington high school player also died. The high school player, according to Q13 Fox TV, was determined the King County medical examiner to be hypertrophic cardiomyopathy, an abnormal enlargement of the heart.

Football players certainly are not the only one affected. Oklahoma Fox affiliate KXII reported this week that members of the Atoka High School marching band suffered from severe dehydration and heatstroke after they took part in a practice. According to KXII, six members of the Atoka band were taken to a clinic and three were hospitalized.

According to Stearns, there were eight deaths from heatstroke across all levels of football from 2005 to 2009. From 2010 to 2014, there were 14.  Eight players have died since 2015.

Stearns said the encouraging news about heatstroke is that there’s strong data to support the belief that there “is 100 percent survival when it is treated aggressively and appropriately.”

“That is why (the death rate) is very concerning from our perspective,” Stearns said. “We have some cheap, effective interventions that can save lives and we are still seeing deaths.”

Stearns said most heatstroke cases arise during preseason conditioning, when proper medical personnel may not be readily available. “And, unfortunately a lot of policies are not in place to act aggressively enough and quickly enough to treat exertional heatstroke when it does happen,” she said.  “You need policies in place, so everyone is aware of what steps should be taken and you need a medical professional present who can identify the condition. Unfortunately, heatstroke can be confused with many other conditions.”

Stringer died of heatstroke during the Vikings’ 2001 training camp, and the Stringer Institute was created with the hope of preventing sudden deaths in sports.

No NFL players have died of heatstroke since Stringer’s death, but here are college players who have died:

2018: Jordan McNair, University of Maryland: A 19-year-old, 325-pound sophomore offensive lineman, McNair was observed struggling during a May 29 conditioning test at the school, which included multiple 110-yard sprints. He was hospitalized that night and died June 13. The Jordan McNair Foundation announced he died of heatstroke.

2017: Tyler Heintz, Kent State: A coroner confirmed Heintz, 19, a freshman 275-pound offensive lineman, died of heatstroke after completing his second day of conditioning drills at Dix Stadium

2014: Marquese Meadow, Morgan State: According to the Baltimore Sun, he became disoriented after an Aug. 10 practice, was hospitalized, slipped into a coma, and died two weeks later. Cause of death was listed as heatstroke. The high temperature on Aug. 10 was 86 degrees.

2008: Chad Wiley, North Carolina A&T: A fifth-year senior, Wiley complained of dizziness at a voluntary workout on campus. He lost consciousness when he was being treated in the trainer’s room. According to the United Press International, the autopsy showed Wiley died of heatstroke complications, resulting from a sickle cell trait.

2001: Eraste Autin, Florida: An incoming freshman, Autin, a 250-pound fullback was expected to compete for a starting job. But according to the Associated Press, he died of complications from heatstroke after collapsing while jogging back to the locker room after a voluntary conditioning session.

Source: USA Today

Maryland places athletic staffers on leave in wake of football player’s death (Washington Post)

The University of Maryland placed multiple members of its athletics staff on administrative leave as an external review of the death of football player Jordan McNair continues, a school spokesman confirmed Friday.

Maryland would not specify which staff members were placed on leave, calling it a “personnel issue” and saying in a statement, “We will be able to speak in greater detail when the review is complete and shared with the public.” Coach DJ Durkin was seen running practice Friday in footage posted to social media by the Big Ten Network.

The review is being conducted by Walters Inc., an athletic training consulting firm, and is expected to conclude Sept. 15, according to a contract obtained by The Washington Post through a public records request.

McNair, an offensive lineman, died June 13 after suffering heatstroke at a team workout May 29. He was 19. McNair’s parents announced the cause of death in early July on a website promoting the Jordan McNair Foundation, which they started after their son’s death. Attorney Billy Murphy, who is helping the family explore legal options, told The Post on Friday that a lawsuit is likely.

Maryland started training camp last week and has not opened practice to reporters, nor has it made coaches or players available for interviews.

An ESPN story published late Friday afternoon, citing former staffers and current and former players, described a toxic Maryland football culture that includes an “environment based on fear and humiliation,” regular verbal abuse of players and an encouragement of unhealthy eating habits to gain weight. The story depicts a culture that was cultivated by Durkin and largely carried out by strength and conditioning coach Rick Court.

Through a spokesman, the university declined to comment on the ESPN report Friday night. Efforts to reach Court were unsuccessful.

Court was one of Durkin’s first hires when the coach came to Maryland in 2015, and he heads the strength and conditioning staff that supervised the workout that led to McNair’s hospitalization. A former Maryland football player, who was on the team for Durkin’s two seasons with the program, told The Post that Court “was always cursing and yelling at guys, calling them names.”

“That was just Rick; it was all him,” said the player, who painted a culture that mirrored the one described by the ESPN story. The player, who played one season under former coach Randy Edsall, noted that the atmosphere he described began with Durkin’s first year in the program. “There was just constant degrading of players, and that was the culture they brought to the program, and they thought it would toughen us up.”

In a 2017 story on Court, Durkin told The Post: “To me, if the head coach and the strength coach are not totally in line with one another, there’s something that’s going to miss. Me and Rick are in line.”

The former player confirmed to The Post that a former offensive lineman was forced to eat candy bars while watching his teammates work out, a tactic used to embarrass him into losing weight. The former player also said Court once made an injured player participate in a tug-of-war against a group of teammates, and the player was berated by Court when he did not win. Players who won a game of tug-of-war were the first to eat breakfast, the former player said, and he added, “We showed up everyday sort of scared of what may happen. It was kind of crazy.”

He also said that an injured player’s locker was moved to the showers as a way to “humiliate him, which really wasn’t necessary.” Maryland players are encouraged to finish workouts at all costs, multiple people have told The Post, and are degraded if they are unable to do so.

“It became the standard. No one was going to accept, ‘I just won’t finish the workout because I’m exhausted.’ You had to finish,” the former player told The Post on Friday. “Workouts determine if you are going to play for Coach Durkin. If you show you can’t work out to that standard, then you’re not going to see playing time. I don’t know how it is in other programs, but if you show weakness during workouts, I’m pretty sure [Durkin] is automatically going to think that, when the pads come on and it’s time to play, he can’t trust you.”

The May 29 workout was supervised by Maryland’s strength and conditioning staff, and athletic trainers were present throughout, according to a loose account of the day provided by the university. Durkin was also at the workout, which was held at Maryland’s outdoor practice facilities in roughly 80-degree weather. McNair had trouble recovering from a conditioning test that consisted of 10 110-yard sprints, according to the university. Seizures are a known symptom of exertional heatstroke.

ESPN reported Friday that McNair suffered a seizure around 5 p.m., according to his attorney, 45 minutes into the team workout. An incident report written by Prince George’s County medical responders, obtained by The Post through a public records request, shows that a first 911 call was made at 5:57 p.m. and a second was made 10 minutes later. McNair was transported to nearby Washington Adventist Hospital, where he arrived at 6:36, and was soon airlifted to R Adams Cowley Shock Trauma Center in Baltimore. That is where McNair remained until his death.

Multiple medical experts said death from exertional heatstroke is 100 percent preventable if a patient is submerged in a cold-water tub and the body temperature is cooled to 104 degrees within 30 minutes of symptoms appearing. It is unclear whether Maryland treated McNair with cold-water immersion after he started showing symptoms of heatstroke, though Murphy told ESPN that McNair “presented at the hospital with a temperature of 106, which means he was not cooled down.”

“The bottom line when you look at a case like this, and I’m not doing this to point blame or anything, but there was something done incorrectly in this situation,” Douglas Casa, chief executive of the Korey Stringer Institute at the University of Connecticut, told The Post last month. The institute — named for the NFL player who died after suffering complications brought on by heatstroke in 2001 — works to prevent sudden death in sport. “We know that because he died from heatstroke, and within an organized sports setting, no one should die from heatstroke.

“It would be different if you had a situation that was 70 percent effective or 60 percent effective; this is 100 percent effective if you utilize cold-water immersion within 30 minutes and you get someone’s temperature down rapidly. It’s not hard to get someone’s temperature down to 104 within 30 minutes if you use the right cooling modality.”

Roman Stubbs contributed to this report.

Source: Washington Post

KSI Summer 2018 Conferences









2018 ACSM National Conference

Yasuki Sekiguchi, MS, CSCS, Associate Director of Athlete Performance and Safety

The American College of Sports Medicine (ACSM) Annual Meeting was held in Minneapolis from May 29 – June 2. Most of the KSI staff attended this outstanding conference and they were honored with the opportunities to present their research. We had great discussions with other attendees and received feedback for future work via these presentations.

  • Douglas J. Casa, PhD, ATC, FACSM- Alcohol and hydration
  • Ryan M. Curtis, MS, ATC, CSCS- The effects of sleep duration on sleep quality in elite soccer athletes
  • Courteney L. Benjamin, MS, CSCS- Sleeping patterns of NCAA D1 collegiate athletes: A sex comparison
  • Gabrielle EW. Giersch, MS- Validity and reliability of a short-based integrated GPS sensor
  • Gabe also did an excellent job as a moderator of the hydration thematic poster session with Dr. Cheuvront
  • Rachel K. Katch, MS, ATC- Effects of wrist cooling on balance and cognitive performance in the heat
  • Yasuki Sekiguchi, MS, CSCS- Factors influencing hydration status during a NCAA Division 1 soccer preseason
  • William M. Adams, PhD, ATC- Hormonal, steroidal and inflammatory responses in collegiate male soccer players and female cross-country runners
  • Yuri Hosokawa, PhD, ATC- Comparison of rectal temperature responses during a modified heat tolerance test

Attending this conference allows the KSI staff to obtain further knowledge, skills and new ideas as well as make new relationships with other professionals. This conference certainly helps to develop KSI and execute our goals to maximize performance, optimize safety and prevent sudden death for the athlete, soldier and laborer. The KSI staff members are thankful to all of the presenters and attendees for their contributions to this field as well as helping make this conference one where individuals who are passionate about similar topics can meet, collaborate, and enjoy one another.





2018 NATA Clinical Symposia

Alicia Pike, MS, ATC, Director of Education

View of the Mississippi River near the Convention Center

During the last week of June, a majority of the KSI staff traveled to the “Big Easy” for the 69thannual National Athletic Trainers’ Association Clinical Symposia. New Orleans may have been ready for us, but we sure weren’t ready to face the very hot and humid days. Despite the sweltering weather, this year’s conference was filled with presentations and meetings that not only showcased the numerous projects KSI is actively engaged in, but also served as a platform to continue our mission of optimizing safety and preventing sudden death in sport.


The week kicked off with our Medical & Science Advisory Board Meeting at one of Dr. Casa’s favorite restaurants – Bubba Gump Shrimp Co. We were very thankful to have so many familiar faces in the room, and even saw a little competitiveness come out in a friendly game of Bubba Gump Trivia. Following dinner and a lot of laughs, Dr. Casa spoke to the Board regarding the recent accomplishments of KSI, especially three primary initiatives that have been the focus over the last couple years: (1) the ‘Raise Your Rank Campaign’, a state-specific approach aimed at improving mandated best practices policies to reduce catastrophic injuries in sport, (2) the Athletic Training Locations and Services (ATLAS) database, which has now officially mapped the extent of athletic trainer services provided to every public and private secondary schoolacross the United States, and (3) the Perceptions of Athletic Training study, which is currently assessing perceptions of the profession from athletic directors, principals, superintendents, legislators, coaches, and parents in order to develop educational strategies to further raise awareness of the value of the athletic training profession.

The remaining days of the conference flew by, as they always do, with various presentations by our staff members. The following presentations showcased the work of KSI at this year’s conference:

  • Rebecca Stearns & Alicia Pike- Legislators Perceptions of the Athletic Training Profession
  • Samantha Scarneo- Implementation of Emergency Action Plan Policies in Secondary School Athletics Without Previous Athletic Training Services
  • Brad Endres- Epidemiology of Sudden Death in Adult Organized Recreational Sport in the United States, 2007-2016
  • Robert Huggins:- Athletic Trainer Services in the Secondary School Setting: The ATLAS Project
  • Rebecca Stearns- Heat Tolerance Test Results from Exertional Heat Stroke Patients Receiving Cold Water Immersion Treatment
  • Sarah Attanasio- Athletic Trainer Education Level and Employment Models: The ATLAS Project

In addition to the presentations, our staff enjoyed manning the KSI booth at the NATA Expo. We love when people stop by; even if it’s to tell us a personal story, talk to us about one of our presentations they attended, or reach out to us as a resource for whatever circumstance they may be encountering in their current clinical position or state. Every year we have more attendees stop by and share with us how they’ve heard about KSI or thank us for the work we do to improve health and safety for student-athletes. It really is the biggest motivation to continue our mission day after day.

The 2018 conference was a unique one for KSI, since we also held two separate events to raise awareness and support initiatives we are currently engaged in. The first was a ‘launch event’ for the Comprehensive Safety Initiative (CSI), a collaborative effort between KSI, University of Connecticut, University of North Carolina at Chapel Hill, and Player’s Health, to help secondary school athletic trainers identify areas for improvement related to health and safety best practice adoption. A comprehensive library of resources will be accessible on the Player’s Health platform by the end of 2018. All secondary school athletic trainers are encouraged to complete the Safety Needs Assessment located at:

The second event was held for all athletic trainers currently employed at high schools who were recipients of the NFL Athletic Trainer Pilot Grant, an initiative aimed at providing secondary schools with resources to start or enhance their athletic training programs. June 2018 marked the end of year one of the pilot grant program, so we invited the athletic trainers currently employed at these schools to attend the meeting, provide them with more detailed information related to the grant program, but more importantly, debrief about their first year and offer as much support to them as possible. The meeting was a success, and not only gave us the chance to meet the athletic trainers in person, but also served as a platform to receive valuable feedback to improve the program in the next two pilot years.

Now the conference really can’t be all work and no play…when in New Orleans, do as the New Orleaners do! We were very fortunate to have our own personal tour of the city from a KSI benefactor, massive supporter, and close friend of Dr. Casa’s, Scott Chafin. Scott, along with colleagues from his law firm, brought us around NOLA for four hours of unforgettable fun. From the Garden District, to an amazing seafood dinner, followed by authentic Italian dessert, and of course, some trolley karaoke, it was a night we are forever thankful for and will never forget.



It was a very busy, yet rewarding week, and the perfect opportunity to share the work of KSI with athletic trainers across the country. Perhaps my favorite quote of all time is “Alone we can do so little; together we can do so much,” and this year’s conference truly made me realize how muchwe’ve done and how muchwe will continue to do.






2018 Hydration for Health Conference 

Gabrielle Giersch, MS, Associate Director of Research


I had the great opportunity to attend the 10th Annual Hydration for Health Conference in Evian, France. I was able to present research from a study done in collaboration with Dr. Lawrence Armstrong and Dr. Elaine Lee that investigated the role of fluid restriction on perceived sleep duration and quality. This research was presented as a part of the “Pitch Your Science” contest for the Young Researcher Award that consisted of a consolidated 3-minute presentation in a specific session of the conference. This conference is unique in that it unites several disciplines all with specific interest in hydration for health outcomes. This conference provides a great opportunity for a variety of disciplines to discuss with international colleagues on the role of hydration on overall health.







2018 NSCA National Conference

Courteney Benjamin, MS, CSCS, Director of Education & Associate Director of Athlete Performance and Safety

The 2018 NSCA National Conference was held in the beautiful city of Indianapolis, Indiana- home to the NCAA and ACSM headquarters. Members of KSI had the great opportunity to present some of our research during this July conference.

  • Yasuki Sekiguchi- Relationships between resting heart rate, heart rate variability, and sleep characteristics among female collegiate cross-country athletes
  • Ryan Curtis- Sleep Distribution and heart rate-derived autonomic nervous system responses to acute training load changes in collegiate soccer players
  • Courteney Benjamin- Effects of Early Morning Training on Sleep in NCAA Division 1 Female Cross-Country Runners

I was also awarded the opportunity to give a featured presentation titled, “What S&C coaches need to know to prevent sudden death in sports.” During this talk, I reviewed the 2012 best practices document related to collegiate strength and conditioning as well as discussed how this profession can continue to advance by ensuring the safety of athletes.

This talk could not have come at a better time as the NSCA president, Dr. Greg Hoff would announce exciting changes surrounding requirements for obtaining a CSCS certification at the opening ceremonies. According to an article released by the NSCA on July 12th, 2018 the certification process will change as follows.

There will be two principal changes to the certification process:

  1. Effective target date 2030, all CSCS exam candidates must hold a Bachelor’s degree in a strength and conditioning related field, or be enrolled as a senior in such a program.
  2. Effective target date 2030, candidates will need to obtain those degrees from a college or university that has a program accredited by an NSCA-approved accrediting agency.

This conference was a great opportunity to meet other professionals in this field as well as establish relationships for future collaborations. We look forward to attending this conference again next year!


Off Your Mental Game? You Could Be Mildly Dehydrated (NPR)

Was it hard to concentrate during that long meeting? Or, does the crossword seem a little tougher? You could be mildly dehydrated.

A growing body of evidence finds that being just a little dehydrated is tied to a range of subtle effects — from mood changes to muddled thinking.

“We find that when people are mildly dehydrated they really don’t do as well on tasks that require complex processing or on tasks that require a lot of their attention,” says Mindy Millard-Stafford, director of the Exercise Physiology Laboratory at Georgia Institute of Technology. She published an analysis of the evidence this month, based on 33 studies.

How long does it take to become mildly dehydrated in the summer heat? Not long at all, studies show, especially when you exercise outdoors.

“If I were hiking at moderate intensity for one hour, I could reach about 1.5 percent to 2 percent dehydration,” says Doug Casa, a professor of kinesiology at the University of Connecticut, and CEO of the Korey Stringer Institute.

For an average-size person, 2 percent dehydration equates to sweating out about a liter of water.

“Most people don’t realize how high their sweat rate is in the heat,” Casa says. If you’re going hard during a run, you can reach that level of dehydration in about 30 minutes.

And, at this level of dehydration the feeling of thirst, for many of us, is only just beginning to kick in. “Most people can’t perceive that they’re 1.5 percent dehydrated,” Casa says.

But, already, there are subtle — maybe even imperceptible — effects on our bodies and our mental performance.

Take, for example, the findings from a recent study of young, healthy and active women who agreed to take a bunch of cognitive tests, and also agreed to restrict their fluid intake to no more than six ounces for one day.

“We did manage to dehydrate them by [about] 1 percent just by telling them not to drink for the day,” says Nina Stachenfeld of the Yale School of Medicine and the John B. Pierce Laboratory, who led the research.

The women took one test designed to measure cognitive flexibility. It’s a card game that requires a lot of attention, since the rules keep changing throughout the game.

“When the women were dehydrated they had about 12 percent more total errors” in the game, says Stachenfeld.

She repeated the tests after the women drank sufficient water, and their performance improved. “We were able to improve executive function back to normal — in other words— back to the baseline day — when they rehydrated,” the scientist says.

Dehydration didn’t hamper performance on all the tests; the women’s reaction time, for example was not impeded. The decline was seen during thecomplicated tasks.

Though the study was small, and funded by PepsiCo, which sells bottled water, Stachenfeld designed the methods and completed the analysis independently. And other scientists say her findings fit with a growing body of independent evidence that points to similar conclusions.

“I absolutely think there could be big implications of having a mild cognitive deficiency with small amounts of dehydration,” Casa says.

If you’re a student, for example, a 12 percent increase in errors on a test might matter. And whether you’re a pilot, a soldier, a surgeon or a scholar, many daily tasks depend on the ability to be precise and pay attention.

For anyone trying to do their best work, the findings raise a number of questions:

How much water do we need?

There are no exact daily requirements, but there are general recommendations.

A panel of scholars convened several years ago by the National Academies of Sciences, Engineering and Medicine concluded that women should consume, on average, about 91 ounces of total water per day. For men, the suggested level is even higher (125 ounces).

Note that this total includes water from all sources, including food and other beverages, such as coffee and tea. Typically, people get about 20 percent of the water they need daily from fruits, vegetables and other food.

Also, water needs vary from person to person. For example, body weight and muscle mass matter. Also, physical activity and heat exposure can increase the amount of fluid a person needs.

How can you tell if you’re dehydrated?

One easy test: The color of your urine is a good guide. As a general rule of thumb, the darker the color, the more likely you are to be dehydrated. Aim for shades that have been described as “pale lemonade” or “straw.” A color chart developed by physiologist and University of Connecticut professor Lawrence Armstrong can be a helpful guide, researchers say.

Are older people more vulnerable to dehydration?

As we age, we’re not as good at recognizing thirst. And there’s evidence that older adults are prone to the same dips in mental sharpness as anyone else when mildly dehydrated.

Don’t wait until you’re thirsty. A good rule of thumb is to sip fluids throughout the day. No need to chug huge amounts at one time; there are some risks to overhydrating, too.

Can coffee, tea and other caffeinated drinks have a dehydrating effect?

The most recent evidence finds that coffee provides similar hydrating qualities to water. In other words, yes, your morning cup of joe — or whatever caffeinated beverage you fancy, can help to keep you hydrated.

As we reported in 2014, people who routinely drink coffee or tea develop a tolerance to the potential diuretic effects of caffeine.

Source: NPR