EXERTIONAL HEAT STROKE

HEAT STROKE (AND ILLNESS) IS A MEDICAL EMERGENCY.

COOL FIRST, WHILE CALLING CALL 911, AND TRANSPORT SECOND.

REMOVE THE UNIFORM AND PLACE THE ATHLETE INTO A KIDDY POOL FULL OF ICE WATER INSTANTLY.

EVERYOUTDOOR PRACTICE AND GAME FIELD, DURING WARM WEATHER, SHOULD HAVE A KIDDY POOL (WALMART, COST ~ $50-75) STANDING BY WITH WATER HOSE AND LARGE FULL ICE CHEST READY TO POUR INTO POOL,
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KENTUCKY MEDICAL ASSOCIATION / KENTUCKY HIGH SCHOOL ATHLETIC ASSOCIATION PROCEDURE FOR AVOIDING HEAT INJURY / ILLNESS THROUGH ANALYSIS OF HEAT INDEX AND

RESTRUCTURING OF ACTIVITIES
Complete listing of support documents available at http://www.khsaa.org/sportsmedicine/

INTRODUCTION

“Following months of study, after one year of implementation and in an effort to help protect the health and safety of student-athletes participating in high school sports, the Kentucky Medical Association Committee on Physical

Education and Medical Aspects of Sports issued a recommended procedure to the Kentucky High School Athletic Association for immediate implementation in 2002. This
procedure called for the determination of the Heat Index (using on site devices to measure Temperature and Relative Humidity), and a guideline for activity to be conducted at that time based on the Heat Index reading. Though other procedures and measurements were considered, the application of the Heat Index appeared to be most readily implementable on a state wide basis, and appeared to be reliably tested in other areas.

Through the first five years of use of the procedure, minor adjustments were made in the reporting requirements, and the on site devices to be used. In May, 2005, the Board of Control through its policies directed that all member school comply with the testing and reporting requirements. In October, 2006, the member schools of the Association overwhelming approved at their Annual Meeting, a proposal to make such reporting not simply a Board of Control policy, but a school supported and approved Bylaw as it approved Proposal 9 to amend KHSAA Bylaw 17
(http://www.khsaa.org/annualmeeting/20062007/annualmeetingproposals20062007.pdf )

In March, 2007, the Kentucky Medical Association Committee on Physical Education and Medical Aspects of Sports recommended the elimination of all devices with the exception of the Digital Sling Psychrometer as a means of measuring at the competition/practice site.

GENERAL PROCEDURE

The procedure calls for the determination of the Temperature and Relative Humidity at the practice / contest site using a Digital Sling psychrometer It is important to note that media-related temperature readings (such as the Weather Channel, local radio, etc.), or even other readings in the general proximity are not permitted as they may not yield defensible results when considering the recommended scale. The readings must be made at the site.

Neither the KHSAA nor KMA has endorsed any particular brand of psychrometer and receives no endorsement fee or other consideration for any device sold. There are several models on the market that will properly perform the functions, including companies such as Medco and others.

The KHSAA or your local Certified Athletic Trainer haseasy access to catalogs with this type of equipment. In addition, the KHSAA web site has a variety of links to various dealers.

INDOOR AND OUTDOOR VENUES

While much of the original discussion concerning this package centered on outdoor sports, the Kentucky Medical Association Committee on Physical Education and Medical Aspects of Sports has advised the KHSAA that indoor sports, particularly in times of year or facilities where air conditioning may not be available, should be included in the testing. Such has been approved by the Board of Control as policy requirement. The recommendations contained in this package clearly cover both indoor and outdoor activity, as well as contact and non-contact sports.

PROCEDURE FOR TESTING

Thirty (30) minutes prior to the start of activity, temperature and humidity readings should be taken at the practice / competition site.

The information should be recorded on KHSAA Form GE20 and these records shall be available for inspection upon request. All schools will be required to submit this form. For 2007, there will be online reporting for submitting this form.

The temperature and humidity should be factored into the Heat Index Calculation and Chart and a determination made as to the Heat Index. If schools are utilizing a digital sling psychrometer that calculates the Heat Index, that number may be used to apply to the regulation table.

If a reading is determined whereby activity is to be decreased (above 95 degrees Heat Index), then re-readings would be required every thirty (30) minutes to determine if further activity should be eliminated or preventative steps taken, or if an increased level of activity can resume.”
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HEAT STROKE IN SPORTS: CAUSES, PREVENTION, AND TREATMENT
E. Randy Eichner, M.D.
Professor of Medicine
Team Internist, Oklahoma Sooners
Department of Medicine
University of Oklahoma Health Sciences Center
Oklahoma City, Oklahoma
Reprinted from Gatorade Sports Science Institute “Sports Science Exchange” Volume 15 Number 3

KEY POINTS
Heat stroke is always a risk in summer sports, especially football and running.
Heat stroke is typically caused by a combination of hot environment, strenuous exercise, clothing that limits evaporation of sweat, inadequate adaptation to the heat, too much body fat, and/or lack of fitness.

Early recognition and fast treatment of evolving heat stroke can save lives.
Preventing heat stroke hinges on acclimation, hydration, pacing, cooling, and vigilance.

Heat stroke is a medical emergency. The life-saving adage is: cool first and transport second.

INTRODUCTION

Summer football brings grueling workouts in brutal heat. For football players in the dog days, mild heat illness is common and grave heat stroke always a threat (Knochel, 1975). Since 1995, on average three players a year have died of heat stroke. Heat stroke also threatens runners and other athletes; in the 2001 Chicago Marathon, a young man in his first marathon collapsed of heat stroke at 26 miles and died soon after.

Heat illness can advance quickly in football players and runners, and early warning signs of heat stroke can be subtle. Yet early diagnosis and proper therapy can save lives; exertional heat stroke should be preventable. This article covers causes of heat stroke in sports and presents tips to recognition, prevention, and treatment.

RESEARCH REVIEW
Causes of Heat Stroke

Overmotivation.

Overmotivated athletes can overheat by doing too much too fast or trying to endure too long. An Australian runner, out of shape, sped to the front of a hot race and kept going hard until he dropped from heat stroke at 4.5 miles (Lee et al., 1990). The same happened to a novice runner who, on a mild day, sped up at the end of a six-mile race (Hanson et al., 1979). Both runners were lucky to live; speed and metabolic rate influence rectal temperature in distance racing (Noakes et al., 1991).

Agonizing tableaus of endurance were seen at the 1984 Los Angeles Olympic Games and the 1995 Hawaii Ironman Triathlon. In Los Angeles, marathoner Gabriela Andersen- Scheiss, not trained for heat, entered the stadium dazed and wobbling. In a final lap that seemed to last forever, she waved off help and collapsed at the finish. In Hawaii, seven-time winner Paula Newby-Fraser, losing her lead, skipped aid stations late in the run and collapsed near the end. After rest, cooling, and hydration, she was able to walk to the finish (Eichner, 1998).

Similar lessons come from the military. A soldier died of heat stroke marching at night, carrying extra weight. He completed just 2.5 miles (Assia et al., 1985). Running generates about twice the heat of marching. Of 82 heat-stroke cases in Israeli soldiers, 40% were from brief exercise, as in the first three miles of a run. Overmotivation was a risk factor (Epstein et al., 1999).

Football breeds a warrior mentality. Victims of heat stroke are described as “the hardest worker” or “determined to prove himself.” During a hard practice on a hot day, the never-quit mentality can work against a player.

The 1-2 Punch.

Most heat-stroke deaths in football occur on Day 1 or 2 of two-a-days. A similar 1-2 punch applies in the military. In studying 1,454 cases of heat illness in Marine-recruit training, researchers implicated heat stress on the prior day as a factor (Kark et al., 1996). So a prime time for heat stroke is the day after an exhausting and dehydrating day in the heat.

Heat and Humidity.

In summer sports, it?s not the heat, but the heat and humidity. In football, body temperature rises ? in a sawtooth line ? ever higher the longer practice goes on. So during a hard practice in full gear, heat stroke is possible at any combination of ambient temperature above 80 °F (26.7 °C) and relative humidity above 40% (Kulka & Kenney, 2002).

Unacclimated.

Getting heat-fit takes time. Lack of acclimation is a cardinal predictor of heat stroke in football. Triathletes unacclimated to the tropical heat of Hawaii also suffer. Acclimation, much of which occurs in a week or two, leads to better drinking and the body holds onto water and salt, increasing blood volume so the heart pumps more blood at a lower heart rate. Heat-fit athletes also sweat sooner, in greater volume, and over a wider body area, so they stay cooler.

Dehydration.

Athletes in the heat can sweat 1-2 L an hour, and most athletes drink less than they sweat. The result is dehydration. Dehydrating only 2% body weight ? just five pounds in a 250-pound linebacker ? can impair physical performance (Walsh et al., 1994). Dehydration increases heart rate and decreases cardiac output. Perceived exertion of the work increases as dehydration drains mental sharpness and willpower along with muscle power and endurance. Dehydrated players also heat up faster (Latzka & Montain, 1999).

Uniform Penalty.

The football uniform insulates players. As more gear is added ? from shorts and shirt to pads and helmet to full uniform ? players heat up faster, get hotter, and cool slower (Kulka & Kenney, 2002). Runners too should avoid vapor-impermeable clothing that limits sweat evaporation. In 1999, actor Martin Lawrence jogged in heavy clothes and a wool hat in 100 °F (37.8 °C) to lose weight. He collapsed with a temperature of 107 °F (41.7 °C) and spent three days in a coma.

Heat Stroke and Body Mass.

Fat athletes are prone to heat stroke. Extra fat is an extra load, increasing exertional heat production. The NFL has nearly 300 players who weigh 300 pounds or more, six times as many as a decade ago. Nor is extra fat the only bulk problem. When a 270-pound player adds 30 pounds of muscle, he can generate more heat, but he does not add enough extra surface area to shed that extra heat. So huge lineman can be heat bombs.

Fitness Protects.

Physical fitness, especially aerobic fitness, confers some of the same physiologic benefits as heat acclimation (Latzka & Montain, 1999). Fitness also makes workouts less taxing. So football players who come to camp fit are at lower risk of heat stroke.

In contrast, lack of fitness increases risk of heat illness. In a study of 391 cases of heat illness in Marine recruits, time to run 1.5 miles (and body mass index) predicted risk. A recruit unable to run 1.5 miles in 12 minutes (and with a body mass index over 22) had eight times the risk of heat illness in basic training as did one with a lower body mass and faster run time (Gardner et al., 1996).

Supplements.

Stimulants speed heat buildup, so products that speed players up heat them up. Amphetamine and cocaine are the most dangerous, but ephedra is the most prevalent. Many dietary supplements tout ephedra for weight loss or quick energy. But ephedra poses many health risks, including heat stroke. Heat-stroke risk is compounded by drugs that impair sweating, like some antihistamines, antispasmodics, and medications for depression.

Recognizing Heat Stroke

Beyond Fluids.

Heat stroke in football sometimes seems to hit with surprising speed. When this happens, a common theme of bewildered staff is, “But he got lots of fluids.” The misconception is that hydration prevents heat stroke. The truth is that hydrating is critical but not sufficient to prevent heat stroke. Stress fluids but think “beyond fluids.” All the factors described above can work together to cause heat stroke.

Compared to the other common causes of collapse in football ? trauma, heart disease, asthma, sudden blood clots tied to sickle cell trait (sickling crisis) ? heat stroke is often slow to evolve, and the vigilant observer can detect early warning signs and avoid the worst outcome. Heat stroke is always a threat during hard drills on hot days, especially in hefty players in full gear.

Early Warning.

Early warning signs of impending heat stroke may include irritability, confusion, apathy, belligerence, emotional instability, or irrational behavior. The coach may be the first to note that a player, heating up, can no longer think clearly. Giddiness, undue fatigue, and vomiting can also be early signs. Paradoxical chills and goose bumps signal shutdown of skin circulation, portending a faster rise in temperature. The player may hyperventilate ? just as a dog pants ? to shed heat; this can cause tingling fingers as a prelude to collapse. Incoordination and staggering ? “running like a puppet on a string”? are late signs, followed by collapse with seizure and/or coma. Upon collapse, as in all three football players who died in 2001, core body temperature can be 108 °F (42.2 °C) or higher.

Preventing Heat Stroke

Cooler is Better.

The cooler athletes stay, the better they play. In team sports, take frequent cooling breaks. Provide shade, ice water, and misting fans for rest breaks. As the temperature rises, reduce practice pace and duration and increase rest breaks. Have players sit in cold tubs after practice. Hold practices earlier and later, with more time between ? time for rest, recovery, and cooling.

In hot road races, tips include: stay hydrated; run comfortably, avoid long sprints; “read” your body; and seek help early for illness. Confusion can limit self-diagnosis, so race monitors can help. Runners in trouble can become belligerent, refusing to stop until they collapse. Naïve crowds may urge on suffering athletes, chanting, “Keep going, you can make it.” Monitors can recognize early warning: incoherence, irrational or bizarre behavior, or poor competitive posture (Eichner, 1998).

Drink Sensibly.

Hydration helps prevent heat stroke, but there is no advantage to consuming fluid in excess of sweat loss. Likewise it?s not necessary to overhydrate the night before or during the hours prior to a long run or practice. Teach athletes to drink for their needs. During training have them weigh in before and after a workout and learn to adjust fluid intake to minimize weight loss. If weight loss does occur, rehydration after activity is critical; drink 20-24 ounces of fluid for every pound of weight loss. Also, eat foods with a high water content (fruits & vegetables). A sports drink beats plain water because it has sugars to fuel muscles and brain, flavoring to encourage drinking, and sodium to hold fluid in the body and help replace sweat losses.

Be Prepared.

High heat can overwhelm even physically fit and hydrated players. A week or two of moderate physical activity in the heat, say jogging 30-45 minutes a day, can jump-start heat acclimation. Athletes should never go from a sedentary, airconditioned life into a hard-charging summer athletic camp.

Bird-dog the Big Guys.

In football, focus on high-risk players. Spot subtle signs of physical or cognitive decline. Weight loss the first few days is fluid loss, not fat loss. Dizziness and drop in blood pressure on standing signal fluid and sodium depletion. Urine should resemble lemonade, not apple juice. Weigh before and after practice. Morning weight should be back up, near baseline, and body temperature should be normal before the player takes the field. When in doubt, hold them out.

Uniform Concerns.

In football, limit gear in the heat. Suit-up in stages in summer camp: shorts and T-shirt the first day or two; then add helmet; then shoulder pads and jersey; finally the full uniform. Remove helmet and pads for fitness runs. Boxers and wrestlers should not run in plastic suits to lose weight.

Counter the Culture.

Some football players are overmotivated by pride and driven by tough coaches. They believe no limits exist. They ignore warning signs. Never let the warrior call the shots. Some runners also have a never-say-die mentality. The man who died of heat stroke in the Chicago Marathon may have pushed the pace trying to keep up with his brother. Heat stroke is rare in female athletes. And in Marines, although attack rates are the same by gender, heat illness is milder in females (Kark et al., 1996). These gender trends raise questions of biology and behavior.

Train, Don’t Strain.

Start slow. Athletes cannot safely start full tilt in stifling heat. Other than massive bleeding, exercising all-out in extreme heat is the greatest strain on the cardiovascular system. Pace and duration should “start low and build slow.” Don?t drive halfway to heaven on the first day.

Off-field Behavior.

Off-field behavior also counts. Athletes sleeping poorly or ill, especially with vomiting, diarrhea, or fever, are more prone to heat stroke. The same applies to taking diuretics or drinking alcohol. Monitor all medications.

Pre-cooling.

Linemen and other athletes at risk of heat stroke may benefit from pre-cooling before workouts. A half hour in a cold bath will reduce core temperature and increase the buffer against heat stroke. Pre-cooling mimics Mother Nature in that after a week of daily exercise in the heat, basal body temperature is reduced about 0.9 °F (0.5 °C) (Buono et al., 1998). Another benefit may be improved hot-weather running or cycling (Booth et al., 1997; Gonzalez-Alonzo et al., 1999). Using cold towels or splashing cold water on face, head, and neck provides a psychological boost but little physiological benefit.

Treating Heat Stroke

Medical Emergency.

In heat stroke, every minute counts. When core temperature is very high, body and brain cells begin to die, so fast cooling is vital. Early features are subtle central nervous system (CNS) changes ? altered cognition or behavior ? and core temperature over 104-105 °F (40.0-40.6 °C). When an athlete collapses, the best gauge of core temperature is rectal temperature; oral, axillary, or ear-canal temperature will not do. Advanced features are collapse with wet skin, core temperature over 106-107 °F (41.1- 41.7 °C) and striking CNS changes ? delirium, stupor, seizures, or coma (Roberts, 1998).

Cool First.

Field treatment is fast cooling. No faster way to cool exists than dumping the athlete into an ice-water tub. Submerge the trunk ? shoulders to hip joints. Research suggests ice-water immersion cools runners twice as fast as air exposure while wrapped in wet towels (Armstrong et al., 1996). The Marines also use ice-water cooling (Kark et al., 1996). Recent field research with volunteer runners suggests cold water may cool as fast as ice water (Clements et al., 2002).

(Walmart Kiddy Pool with Large Ice Cooler and hose located beside. Dump Ice, Water and Athlete in Kiddy Ice Pool instantly. mbmsrmd)

Monitor Closely.

Check the athlete every few minutes for rectal temperature, CNS status, and vital signs. Useful is an indwelling rectal probe with a thermometer. To prevent overcooling, remove the athlete from the tub when rectal temperature drops to 102 °F (38.9 °C). An athlete can be cooled from 108-110 °F (42.2-43.3 °C) to 102 °F (38.9 °C) in 15-30 minutes (Roberts, 1998).

Transport Second.

Cool first, transport second. Send the heat-stroke athlete to the hospital after cooling. With fast cooling, survival rate approaches 100% (Kark et al., 1996). In fact, fast cooling can allow athletes to walk away in good health. For example, yearly at the Falmouth Road Race, up to 10-15 runners collapse with temperatures from 106-110 °F (41.1-43.3 °C), but over a decade nearly all such runners, after ice-water immersion, walked away. After cooling, runners are observed for 20-60 minutes to ensure they are drinking fluids and have normal vital signs and good cognition (Roberts, 1998).

Recovery.

We need more data on recovery. Anecdotally, most runners cooled on-site return to racing in weeks. Some research suggests heat-stroke patients may have brief or lasting heat intolerance, but whether this is innate or a result of the heat stroke is unclear (Shapiro et al., 1979). Other research suggests 90% of heat-stroke patients have normal heat tolerance within two months (Armstrong et al., 1990). Long-term follow-up of 922 cases of heat illness in Marine recruits is encouraging ? subsequent serious heat illness occurs in less than 1% of these Marines per year (Phinney et al., 2001). It seems likely that most athletes treated early for heat stroke and educated on preventing it can return safely to their sport within weeks.

SUMMARY

Many factors ? environmental and personal ? contribute to heat stroke. Early warning signs of impending heat stroke may include irritability, confusion, apathy, belligerence, emotional instability, irrational behavior, giddiness, undue fatigue, chills, goose bumps, and vomiting. Practical tips for preventing and treating heat stroke in sports are outlined, with the vital adage being: Cool first; transport second. Research on recovery is sparse, but it seems likely that most athletes treated early for heat stroke can soon safely return to their sport.

REFERENCES

Assia, A., Y. Epstein, and Y. Shapiro (1985). Fatal heatstroke after a short march at night: a case report. Aviat. Space Environ. Med. 56:441-442.

Armstrong, L.E., J.P. De Luca, and R.W. Hubbard (1990). Time course of recovery and heat acclimation ability of prior exertional heatstroke patients. Med. Sci. Sports Exerc.22:36-48.

Armstrong, L.E., A.E. Crago, R. Adams, W.O. Roberts, and C.M. Maresh (1996). Whole-body cooling of hyperthermic runners: Comparison of two field therapies. Am. J. Emerg. Med. 14:355-358.

Booth, J., F. Marino, and J.J. Ward (1997). Improved running performance in hot humid conditions following whole body precooling. Med. Sci. Sports Exerc.7:943-949.

Buono, M.J., J.H. Heaney, and K.M. Canine (1998). Acclimation to humid heat lowers resting core temperature. Am. J. Physiol. 274:R1295-R1299.

Clements, J.M., D.J. Casa, J.C. Knight, J.M. McClung, A.S. Blake, P.M. Meenen, A.M. Gilmer, and K.A. Caldwell (2002). Ice-water and cold-water immersion provide similar cooling rates in runners with exercise-induced hyperthermia. J. Athl. Train. 37:146-150.

Eichner, E.R. (1998). Treatment of suspected heat illness. Int. J. Sports Med. 19:S150-S153.

Epstein, Y., D.S. Moran, Y. Shapiro, E. Sohar, and J. Shemer (1999). Exertional heat stroke: a case series. Med. Sci. Sports Exerc.31:224-228.

Gardner J.W., J.A. Kark, K. Karnei, J.S. Sanborn, E. Gastaldo, P. Burr, and C.B. Wenger (1996). Risk factors predicting exertional heat illness in male Marine Corps recruits. Med. Sci. Sports Exerc.28:939-944.

Gonzalez-Alonzo, J., C. Teller, S.L. Andersen, F.B. Jensen, T. Hyldig, and B. Nielsen (1999). Influence of body temperature on the development of fatigue during prolonged exercise in the heat. J. Appl. Physiol. 86:1032-1039.

Hanson, P.G. and S.W. Zimmerman (1979). Exertional heatstroke in novice runners. JAMA 242:154-157.

Kark, J.A., P. Q. Burr, C.B. Wenger, E. Gastaldo, and J.W. Gardner (1996). Exertional heat illness in Marine Corps recruit training. Aviat. Space Environ. Med. 67:354-360.

Knochel, J.P. (1975). Dog days and siriasis. How to kill a football player. JAMA 233:513-515.

Kulka, T.J. and W.L. Kenney (2002). Heat balance limits in football uniforms. How different uniform ensembles alter the equation. Phys. Sportsmed. 30(7):29-39.

Latzka, W.A. and S.J. Montain (1999). Water and electrolyte requirements for exercise. Clin. Sports Med. 18:513-524.

Lee, R.P., G.F. Bishop, and C.M. Ashton (1990). Severe heat stroke in an experienced athlete. Med. J. Austr. 153:100-104.

Noakes, T.D., K.H. Myburgh, J. Du Plessis, L. Lang, M. Lambert, C. Van Der Riet, and R. Schall (1991). Metabolic rate, not percent dehydration, predicts rectal temperature in marathon runners. Med. Sci. Sports Exerc.23:443-449.

Phinney, L.T., J.W. Gardner, J.A. Kark, and C.B. Wenger (2001). Long-term follow-up after exertional heat illness during recruit training. Med Sci. Sports Exerc. 33:1443-1448.

Roberts, W.O. (1998). Tub cooling for exertional heatstroke. Phys. Sportsmed. 26(5):111-112.

Shapiro, Y., A. Magazanik, R. Udassin, G. Ben-Baruch, E. Shvartz, and Y. Shoenfeld (1979). Heat intolerance in former heatstroke patients. Ann. Intern. Med. 90:913-916.

Walsh, R.M., T.D. Noakes, J.A. Hawley, and S.C. Dennis (1994). Impaired high-intensity cycling performance time at low levels of dehydration. Int. J. Sports Med. 15:392-398.

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2011 PRESEASON FOOTBALL HEAT STROKE DEATHS

Aug. 8, 2011 New guidelines from American Acadamey of Pediatrics: Sports in Heat OK With Precautions by Lindsey Tanner, AP Medical Writer. That is aDangerous, Reckless Statement by Ivory Tower, White Gowned Doctors not on the Front Line of High School Football with all the information.

“WELL GUESS WHAT, GURDON HIGHT SCHOOL COACH TOOK PRECAUTIONS. THEY WERE PRACTICING AT 8:30pm “

Heat Stroke # 5 this 2011 Preseason- Aug 10, 2011 LITTLE ROCK - Gurdon High School football player died Tues night collapsed ~ 8:30 p.m during a practice. Wed. 15 yo Montel Williams, soph this season, in full-pads practice for over an hour http://www.arkansasonline.com/​news/2011/aug/10/gurdon-high-s​chool-football-player-collapse​s-dies/

4 High School Football Athletes died in the last ~8 days in the South.furing football practice, 1SC, 2GA, 1FL. Probably all heat related. Awaiting Autopsy Reports. sent in email Monday, August 08, 2011 6:31 AM

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Lexington, KY - A Lexington company has begun marketing a body patch that can warn active, outdoor people if their body temperature rises to a dangerous level. The single-use, disposable IONX Body Alert Temperature Patch, created by IONX International, is nicknamed the Hot Dot.

When worn on strategic body parts, the Hot Dot will change color, from black to bright yellow, when the body’s temperature reaches a level that could cause heat stroke or heat exhaustion. After the wearer takes note of the warning and responds by drinking liquids or cooling down, the patch returns to its original black color, signaling that the body’s temperature is within normal range.

The cloth patch has a thermo-chromatic (heat-sensitive) chemical layer in it that changes color based on a temperature setting established in its chemical makeup.

[http://www.bizlex.com/Articles-c-2010-06-23 93326.113117_Predicting_Danger_by_Degrees.html]

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Prepared by Stephen T. Hougen, M.D., F.A.C.S., GETAC Injury Prevention Committee, August 19, 2009 (GETAC - Governor’s EMS & Trauma Advisory Council, Texas Department of State Health Services)

There are no new lessons to be learned about heat stroke, only new athletes, coaches, trainers, and parents to educate. There are no new events, just the same well-known circumstances that are repeated every year with new, unwary victims. At least 21 young athletes have died from heat stroke during the last several years. (30, 31)

The deaths of Korey Stringer, the Minnesota Viking’s Pro Bowl offensive lineman, on August 1, 2001 and Eraste Autin, the University of Florida’s freshman who collapsed July 19, 2001 after a summer training session and spent six days in a coma before dying, are only two of many widely publicized examples of tragic, but preventable, deaths. We may also recall Matthew Thomas, the 14 year old Victoria Texas High School freshman, who succumbed shortly after football practice during a 92-degree afternoon on August 12, 2003, 17 year old Chris Stewart from Oklahoma City who died of heat stroke in August 2005, (21-28) and Max Gilpin, a 15 year-old Louisville, Kentucky player who collapsed and died when his temperature rose to 107 degrees following a series of wind sprints called “gassers” on a 94 degree day in August 2008. (48, 49, 50, 51, 52, 53)

The typical heat stroke victim is usually not well-acclimatized to the Texas heat. It should be no surprise that student athletes who have spent the summer watching TV and playing video games in the comfort of their air-conditioned homes may not be physically prepared for exertion in the heat. (6, 17)

Overall, however, student athletes are extremely motivated, perhaps sometimes even overzealous, individuals who may push themselves beyond their level of endurance and heat tolerance in their attempt to excel in their sport. (17,19,32,43) During team try-outs an athlete may feel pressured to perform beyond his capability in the heat, ignoring signs and symptoms of impending heat-related illness.

When the brain signals that something was wrong, the athlete can override his brain and keep exerting himself. A competitive athlete is not going to voluntarily take himself out of the competition, an action which might jeopardize his place on the team. Disregarding his brain’s signals, the athlete consciously continues to participate beyond the threshold of safety. His brain even starts to fail, manifested by confusion and atypical behavior, as he generates more body heat than he can possibly lose. His body simply overheats.

The human body has a thermal regulation system that strives to maintain temperature at 98.6 degrees Fahrenheit. That temperature is the comfort zone in which all human biological systems operate efficiently. (46) The body dissipates heat with radiation, conduction, convection, and from the evaporation of sweat. (2, 43, 46) Radiation transfers heat energy via infra-red waves from a hotter to a cooler source, like the glow from a red-hot branding iron as skin capillaries dilate to increase blood flow causing the skin to become red and hot. Heat transfer through conduction occurs through direct contact with an object such as heat gain by touching a hot surface or heat loss by direct contact with ice packs or cold water immersion.

Convection occurs when a cool breeze flows over the hot surface causing heat loss into the ambient air much like heat leaving the cooling plates of a car radiator. Finally, the evaporation of sweat also causes heat loss as liquid water turns into water vapor. The cooling effect of sweating islessened by high humidity that prevents evaporation. Sweating is also decreased by dehydration from insufficient water intake, normal respiratory water loss, and fluid losses from vomiting. When fluid losses are great, the body starts to lose intravascular volume—the volume of fluid in arteries and veins. (45)

The pulse rate increases as the heart tries to maintain circulation and an adequate blood pressure. To avoid going into shock, the body closes capillaries to direct blood flow away from the skin, gut, and muscles to more vital organs, such as the brain, kidneys, and liver. (44) When the skin capillaries close, the blood leaves the skin surface. Sweating may stop. The skin becomes cool and clammy and goose bumps may appear. (17, 18, 46) The shunting of blood from the skin is what causes people to feel chilled when going into shock. Vomiting and muscle cramps may occur. (7, 38) The failure of the body’s cooling mechanisms—the radiator effect and the sweating-evaporation process—causes an internal heat surge.

Excessive accumulation of heat energy causes thermal injury to biological systems including breakdown of muscle tissue, rhabdomyolysis, potentially irreversible multi-organ failure, and sometimes death. (2, 8, 9, 12, 16, 17, 32, 43, 46)

Early symptoms of heat injury include: thirst, dizziness, lightheadedness, paleness, headache, poor concentration, missed assignments, irritability, altercations, apathy, weakness, fatigue, and a feeling of being limp. More advanced symptoms include: warm and flushed (red) skin, muscle cramping, nausea, and vomiting.

Emergency symptoms of impending heat stroke include: the appearance of cool and clammy skin, absence of sweating, dry skin, rapid breathing, confusion, a change in personality often perceived as “goofing off” and not following instructions, fainting, and eventual collapse. (2,3,11,12,13,14,17,20,31,43)

Treatment must include immediate rapid cooling in the field with ice packs and cold water, with total body immersion if possible.

Restrictive clothing should be removed. Every minute of exposure at high core temperatures causes more tissue damage. Every minute counts in a “heat” attack, much like a heart attack. (31)

Emergency hospital care is needed for anyone who collapses during heat-related exertion, and rapid cooling should begin in the field and continued during transport to the hospital. (1,12,17,31,32,33,43)

Prevention strategies are the main approach to reducing the risk of exertional heat stroke. The following measures are recommended.

1. Gradually acclimatize participants to heat with light work-outs the first week of practice. Most heat strokes occur during the initial few days of practice when athletes are not acclimatized to the exercise intensity and equipment. (9,17,18,31,32,43,46)

2. Provide free, unlimited, unquestioned access to cool, palatable water. (5,19,30,31,43)

3. If a player is thirsty he is already dehydrated. He must be allowed to drink without having to ask permission. Drinking 8 ounces of a balanced electrolyte solution such as found in sports drinks every 15 minutes, up to a liter per hour, is recommended before a player feels thirsty. A single swallow from a squirt bottle is not sufficient fluid replacement. (9,11,12,13,16,31,43)

4. Weigh players before and after practice to verify proper fluid replacement. If players lose weight during practice, they are dehydrated and at risk of compromising one of their chief means of cooling — sweating. (17,20,43,46)

5. Take mandatory breaks in the shade and allow players to remove helmets. (31,43)
6. Bathroom facilities should be available, as their absence may discourage adequate oral hydration by players who may feel embarrassed if they need to urinate.

7. Although water and balanced electrolyte solutions are helpful, salt tablets are not recommended. (10,11,12,13,14,29) Like drinking seawater, taking salt pills can be harmful. In order to eliminate excess salt the body loses water, water it can not afford to lose during conditions of over-heating. (46,47)

8. Good hydration alone does not prevent heat stroke! Even if one drinks plenty of water and sports drinks and is making lots of dilute urine (a sign of good hydration), heat stroke can still occur if the body generates or absorbs more heat that it can dissipate by its usual cooling mechanisms. (16,17,19,43,46)

9. Exposure to direct sunlight increases the radiant energy absorbed as heat. Test this phenomenon by placing a hand on the hood of a car parked in direct sunlight compared with a car parked in the shade. The air temperature is the same, but the vehicle in the sun is much hotter than the one in the shade. If a practice is held in direct sunlight, the heat index increases by up to 15 degrees F, and those 15 degrees should be added to the heat index given by the National Weather Service to determine the risk of heat-related injury. (2,37)

10. Do not allow any outdoor activity if the heat index is 95 or greater. [mbmsrmd]
11. The above guidelines may vary with the age, weight, and conditioning of individual players. To be on the safe side, in his newspaper column “To Your Good Health” Dr. Paul Donohue recommends suspension of practice if the heat index is 90 or greater (Exertional Heat Stroke, a Preventable Cause of Death, Victoria Advocate, July 14, 2007, page E-5). (35)

12. Monitor players for symptoms of heat exhaustion. (1) A player is unlikely to admit that he is feeling weak or lightheaded. He is unlikely to pull himself out of the practice. A buddy system, like one used by scuba divers, may help one player protect and monitor another. (17,18,31,32,37)

13. If a player is dizzy, lightheaded, not “feeling right” or vomits, he must stop practice immediately and be allowed to cool off in the shade with ice packs and soaked towels, or with a cool water mist and fan, with his uniform removed. Vomiting should prohibit anymore practice that day. Notify the parents so the player is monitored at home and properly fed and rehydrated. (12,13,14,17,31)

14. If a player collapses, or if exertional heat stroke is suspected, a player should be rapidly cooled by immediately removing all equipment and uniforms and immersing him cooled in a tub of ice water until EMS can assume care and transport to the hospital. It is important to cool first, transfer second. Every minute spent above a body core temperature of 104 degrees F, measured rectally or with an esophageal probe, worsens the tissue damage and increases the risk of death.(2, 12, 13, 14, 17, 19, 20,31,32,43,46) Oral, tympanic membrane, and temporal artery temperatures do not accurately measure core temperatures in this setting. (17,43)

15. Avoid stimulants such as highly caffeinated “energy-boosting” drinks (which have fluid-losing diuretic effects), ephedra, ephedrine, amphetamines, and cocaine, which can cause cardiac rhythm disturbances. (2,12,17,32)

16. Practice during the cooler parts of the day, when the heat index is lowest, preferably less than 90, although practice with a heat index of less than 105 may be more practical and acceptable, with appropriate precautions. (17,43)

17. Do not gauge the intensity of practice by pushing players until they get cramps, vomit, or collapse. Remember that if a player is having one symptom, more are likely to follow, possibly in a rapid cascade of downhill events. (32,46)

18. Heat stroke has occurred in marathon runners in relatively cool temperatures of 60 degrees! (32,33,43) The fundamental principle causing exertional heat injury is the generation of heat faster than the heat can be lost. The result is a harmful rise in body core temperature. A core (rectal) temperature of 104 is very dangerous; at 108 the person is likely to die. (1,2,12,16,17,31,38,43,46)

19. The sickle-cell trait, present in 8% of the black population and also found in people of Mediterranean descent, can pre-dispose an athlete to a sickle-cell crisis during times of heat-related stress. A high index of suspicion is necessary when such participants demonstrate any sign or symptom of illness, such as muscle cramps or abdominal pain. Treatment with immediate intravenous hydration and supplemental oxygen may be life-saving and may prevent damage to vital organs. (1,15,17,40,41,42,43)

20. Players who are ill with fever, diarrhea, vomiting, or viral illnesses should refrain from exertion in the heat. (17,19,32,43)

21. Create a team effort to prevent dehydration and heat stroke involving the coaches, trainers, administrators, parents, and athletes. (31)

22. Remember that poor concentration, missed assignments, frequent penalties, irritability, altercations on the field, muscle cramps, loss of liveliness and spirit, apathy, and increasing frustration of the players and coaches in the fourth quarter may be prevented by what is done in the first quarter regarding proper fluid and electrolyte replacement. A player’s poor performance may not be due to lack of desire or not wanting “it” enough. Sub-par performance may simply be due to a lack of water and over-heating! (16,19,31,43) Like continuing to drive a car with a dry radiator, engine failure is likely to occur.

23. Consider posting an educational heat stroke poster in the locker room. (39)

24. Refer to the accompanying temperature/humidity chart to determine the heat index, or use the programs on www.zunis.org to determine the wet bulb globe temperature and follow the football guidelines and recommended precautions. (37)

For example, the National Weather Service uses the Steadman Heat Index on the following page to provide hot weather advisories to the general public. Using the table, an air temperature of 90 with a relative humidity of 60% produces a Heat Index of 100. This heat index is associated with a low risk of heat-related illness, but appropriate precautions should be taken because heat injury can still occur. If players are exposed to direct sunlight, however, the heat index in the same conditions rises to 115 degree F, a danger zone for exertional heat injury. (37)

During practice the coach should ask this question: “Are my players being exposed to direct sunlight casting shadows shorter than their height?” If the answer is “Yes” then add 15 degrees to the heat index chart and take appropriate precautions, such as practicing early in the morning, late in the evening, or inside a gym. (2,37,43)

A heat index of 105 and greater represents a danger zone, and heavy exertion should be avoided. In addition, mandatory breaks in the shade with helmets off and mandatory consumption of 8 ounces of water or a sports drink every 15 minutes should be the rule. A few swallows from a squirt bottle are not sufficient to maintain adequate hydration. Because the judgment of the athlete may be impaired in this setting, the player is unlikely to pull himself out of training exercises. Therefore, trainers and coaches should be observant, monitor their athletes for any symptoms of heat-related illness, and insist that players be removed and protected from dangerous environmental conditions. Prevention and treatment strategies must be in place. (4,5,17,19,43) Remember the advice of experts: “the cooler you stay, the better you play.” (17,18,19)

Note: Exposure to full sunshine can increase HI values by up to 15° F
Alternatively, add 5° F to the temperature when athletes are exposed to direct sunlight

Green Highlighted Heat Index: 90—104. When the heat index is between 90° F and 104° F, heat exhaustion and heat cramps are possible with prolonged exposure and physical activity. Ad lib access to cool water is necessary. Mandatory breaks in the shade every 20 to 30 minutes and extra fluids (water and/or sports drinks) are recommended. Ice water and cold, wet towels for rapid cooling in the shade should be immediately available. Cooling water mist fans are desirable. Observe players carefully!

Yellow Highlighted Heat Index: 105—129. Practice is dangerous in this setting. Under these conditions, instructional “walk-through” drills with minimal running and no contact should be considered. Ad lib access to cool water is necessary. Mandatory breaks in the shade every 15 to 20 minutes and extra fluids (water and/or sports drinks) are needed. An ice water tub for total body immersion or cold, wet towels for rapid cooling in the shade should be immediately available. Cooling mist fans are helpful.

Red Highlighted Heat Index: 130 and Higher. Outdoor exposure and any type of outdoor practice should be prohibited, as heat stroke risk is very great at this level of humidity and temperature. The body’s ability to cool by convection and evaporation of perspiration is severely impaired. In fact, in this environment the body will passively absorb heat from the ambient air and direct sunlight, and cooling by the sweating-evaporation mechanism is not possible because evaporation does not readily occur. Any exertion under these circumstances produces a high risk for exertional heat stroke.

Prepared by Stephen T. Hougen, M.D., F.A.C.S., GETAC Injury Prevention Committee, August 19,2009

Heat Stroke References

1. Vertuno Jim, The Associated Press, Longhorns Tackling the Heat: Pill Helping Texas Survive Rising Temperatures, published by the Victoria Advocate, August 15, 2007.
2. Hyperthermia, Wikipedia Encylopedia, October 2006, Retrieved from “http://en.wikipedia.org/wiki/Hyperthermia”
3. Heat Illness, Heat Exhaustion, Heat Stroke. The Nemours Foundation/Kids Health at www.revolutionhealth.com January 3, 2007.
4. Joseph Rampulla, MS,APRN,BC (June 2004). Hyperthermia & Heat Stroke: Heat-Related Conditions (pdf). The Health Care of Homeless Persons pp.199-204. Boston Health Care for the Homeless Program. Retrieved on 2007-02-22 at: http://www.bhchp.org/BHCHP%20manual/pdf_files/part2_PDF/Hyperthermia.pdf .
5. “Are you ready for extreme heat?” Courtesy: Federal Emergency Management Agency, Department of Homeland Security. Available from FEMA at: www.fema.gov/areyouready/heat.shtm. Updated August 20, 2007. This information may have changed or been updated since it was accessed. For the most current information, contact FEMA at http://www.fema.gov/.
6. Scott Anderson “Preventing Muscle Cramping in Football”. Coach and Athletic Director. May 2001. At www.FindArticles.com, 15 September 2007. http://findarticles.com/p/articles/mi_m0FIH/is_10_70/ai_n18611880 E.
7. Randy Eichner “Muscle cramps: the right ways for the dog days”. Coach and Athletic Director. August 2002. FindArticles.com. 15 Sep. 2007. http://findarticles.com/p/articles/mi_m0FIH/is_1_72/ai_n18613963.
8. Maddali Sirish, Rodeo Scott, Barnes Ronnie, Warren Russell, Murrell George: Post-exercise Increase in Nitric Oxide in Football Players with Muscle Cramps. The American Journal of Sports Medicine 26: 820-824, 1998.
9. Ruiz E J, Mitchell I D, Eberman L E, Cleary M A. Severe dehydration with cramping resulting in exertional rhabdomyolysis in a high school quarterback. In Cleary M A, Eberman LE, Odai ML eds. Proceedings of the Fifth Annual College of Education Research Conference: Section on Allied Health Professions. April 2006; 1: 31-35. Miami: Florida International Univeristy. http://coeweb.fiu.edu/research_conference/.
10. Cleveland Minot. Musle Cramp. University of Illinois Medical Center at Chicago: Health Library, at www.uimc.discoveryhospital.com, March 13, 2000; reviewed January 4, 2007. “Salt tablets are not useful and should be avoided.”
11. Texas Children’s Hospital. Preventing Heat Illness. Texas Children’s Hospital: Caring for Your Child’s Health at www.texaschildrenshospital.org, 2005. “Salt pills are unnecessary and possibly dangerous.”
12. Centers for Disease Control and Prevention. Frequently Asked Questions about Extreme Heat. Emergency Preparedness and Response Website at www.bt.cdc.gov/disasters/extremeheat/faq.asp. August 15, 2006. “Do not take salt tablets unless directed by your doctor.”
13. Gillis Rick (reviewer). Heat-Related Illness Can Quickly Become Serious. Healthlink: Medical College of Wisconsin at:
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www.healthlink.mcw.edu/article/1031002770.html, June 28, 2007. “Salt pills should not be used without first asking your health care provider.”
14. Taylor-Oring Leslie. Is it Heat Exhaustion or Heat Stroke? Tae Park Tae Kwon Do at: www.eod.gvsu.edu/tkd/newpage22.htm. March 14, 1999. “Give them cool liquids—NO SALT PILLS.”
15. Eichner Randy. Curbing Muscle Cramps: More than Oranges and Bananas. Hot Topics in Sports Nutrition. Gatorade Sports Science Institute, at: www.gssiweb.com/ShowArticle.aspx?articled=619. July 25, 2003.
16. Coyle Edward. Fluid and Carbohydrate Replacement During Exercise: How Much and Why? Gatorade Sports Science Institute, Sports Science Exhange #50, Volume7 (1994), Number 3, at: www.gssiweb.com/Article_Detail.aspx/articleid=23&level=2&topic=2.
17. Eichner Randy. Heat Stroke in Sports: Causes, Prevention, and Treatment. Gatorade Sports Science Institute, Sports Science Exchange #86, Volume 15 (2002), Number 3, at: www.gssiweb.com/Article_Detail.aspx?articleid=597&level=2&topic=7.
18. Eichner Randy. Heat Stroke in Sports: How to Protect Yourself and Help Your Teammates. Gatorade Sports Science Institute, Sports Science Exchange #86, Volume 15 (2002), Number 3 Supplement, at: www.gssiweb.com/Article_Detail.aspx?articleid=597&level=2&topic=7.
19. Murray Robert, Eichner Randy. Preventing Heat Illness: Keeping Athletes from Falling into Danger Zones. Gatorade Sports Science Institute, Sports Science Library at: http://gssiweb.com/Article_Detail.aspx?articleid=570&level=2&topic=7.
20. Casa Douglas, Murray Robert. Sports Science News: Preventing Exertional Heat Illness: A Consensus Statement. Gatorade Sports Science Institute, Sports Science Library, 2007, at: http://gssiweb.com/Article_Detail.aspx?articleid=625&level=2&topic=7.
21. Conrad Mark. Mark’s View: Heat Stroke and Football Practice (A comment on the heat stroke death of Minnesota Viking Korey Stringer). Mark’s Sportslaw News, 2001, at: www.sportslawnews.com.
22. CNN News. Vikings football player dies of heat stroke, at: www.CNN.com./U.S., August 1, 2001. This is a CNN news story about Korey Stringer.
23. Associated Press, Mankato, Minnesota. Vikings tackle Stringer dies from heatstroke, August 2001.
24. The Associated Press, Gainesville, Florida: Florida player Autin dies six days after heat stroke. Volume 101, No. 187, Thursday, July 26, 2001. This article discusses the heat stroke death of 18 year old freshman Eraste Autin who collapsed during a work out in 88 degrees, 72% humidity, heat index of 100.
25. Smith Michael. Football Practice Heat Stroke Deaths Preventable (An article about the heat stroke death of 18 year old Chris Stewart). MedPage Today, Daily Headlines, Oklahoma City, August 18, 2005.
26. Sparks Tara. Death has parents concerned. Victoria Advocate, page 1, August 15, 2003 at: www.nl.newsbank.com/nl-search/we/Archives?p_product=VA&P_t.
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This article describes a parents’ safety meeting following the death of 14 year-old Matthew Thomas.
27. Victoria Advocate staff writer. Autopsy not yet released. Victoria Advocate, page 1, August 15, 2003, at: www.nl.newsbank.com/nl-search/we/Archives?p_product=VA&P_t.
28. deLench Brook. To Nineteen Youth Athletes Dying Young. MomsTeam, A Parents Trusted Youth Sports Source, at www.momsteam.com. August 25, 2007.
29. Reddy Vinay. Heat Cramps, Heat Exhaustion, and Heat Stroke. Dr. Reddy’s Pediatric Office on the Web at http://www.drreddy.com, 1/12/07.
30. Williamson David. UNC Warns of Possible Heat Strokes for High School Atheletes, at www.unc.edu//depts/nccsi, 2004.
31. Roberts William. Death in the Heat: Can Football Heat Stroke be Prevented? Current Sports Medicine Reports. (3), 2004.
32. Roberts William. Common Threads in a Random Tapestry: Another Viewpoint on Exertional Heatstroke, The Physician and Sports Medicine. 33(10) 2-5, October 2005.
33. Roberts William. Exertional Heat Stroke during a Cool Weather Marathon: A Case Study. Medicine & Science in Sports & Exercise, Official Journal of the American College of Sports Medicine, pages 1197-1203, January 2006 at http://www.acsm-msse.org.
34. Fighting Heat Stress, at http://fighting_heat_stress,asp.htm.
35. Donohue Paul. Exertional Heat Stroke: A Preventable Cause of Death, To Your Good Health. Victoria Advocate, page E-5, Saturday, July 14, 2007.
36. Jung Alan, Bishop Phillip, Al-Nawwas Ali, Dale Barry. Influence of Hydration and Electolyte Supplementation on Incidence and Time to Onset of Exercise-Associated Muscle Cramps. Journal of Athletic Training 40(2): 71-75, April-June 2005.
37. The Zunis Foundation. How Hot is Hot? How Safe if Safe? At www.zunis.org, April 8, 2007.
38. It’s Hot, It’s Humid, It’s Sunny: Information on Heat and Sun-Related Illnesses. Street Medics, www.action-medical.net
39. Hirsch Larissa. Heat Exhaustion and Heat Stroke: A Poster. This is a handy instructional “Heat Sheet” found at www.kidshealth.com
40. Bergeron Michael F, Cannon Joseph G, Hall Elaina L, Kutlar Abdullah. Erythrocyte Sickling During Exercise and Thermal Stress. Clinical Journal of Sport Medicine. 14(6): 354-356, November 2004.
41. Gallais Daniel Le, Bile Alphonse, Mercier Jacques, Paschel Marc, Tonellot Jean Louis, Dauverchain Jean. Exercise-induced death in sickle cell trait: role of aging, training, and deconditioning. Medicine and Science in Sports and Exercise. 28(5): 541-544, May 1996.
42. Kark J A, Posey D M, Schumacher H R, Ruehle C J. Sickle-cell trait as a risk factor for sudden death in physical training. New England Journal of Medicine. (317): 781-787, September 1987.
43. Binkley Helen M, Beckett Joseph, Casa Douglas J, Kleiner Douglas M, Plummer Paul E. National Athletic Trainers’ Association Position Statement: Exertional
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Heat Illnesses. Journal of Athletic Training. 37(3): 329-343, July-September 2002.
44. Guyton Arthur C, Hall John E. Circulatory Shock and Physiology of its Treatment, Chapter 24, Textbook of Medical Physiology, Eleventh Edition. W.B. Saunders Company, Philadelphia, June 2005.
45. Guyton Arthur C, Hall John E. The Body Fluid Compartments: Extracellular and Intracellular Fluids, Chapter 25, Textbook of Medical Physiology, Eleventh Edition. W.B. Saunders Company, Philadelphia, June 2005.
46. Guyton Arthur C, Hall John E. Body Temperature, Temperature Regulation, and Fever, Chapter 73, Textbook of Medical Physiology, Eleventh Edition. W.B. Saunders Company, Philadelphia, June 2005.
47. Guyton Arthur C, Hall John E. Regulation of Extracellular Fluid Osmolarity and Sodium Concentration, Chapter 28, Textbook of Medical Physiology, Eleventh Edition. W.B. Saunders Company, Philadelphia, June 2005.
48. Graves, Will. Case of Kentucky Coach puts Football on Trial. The Associated Press. The Victoria Advocate, page C-7, Friday, January 30, 2009.
49. Mahalo.com. Max Gilpin, at http://www.mahalo.com/max-gilpin
50. Louisville News, Homepage. Witness: Teen’s Death was Preventable. August 27, 2008. http://www.wlky.com/news/17315849/detail.html Copyright 2008 by WLKY.com.
51. Konz, Antoinette. 911 Call: PRP player drifted in, out of consiousness. Courier-Journal.com, Louisville, Kentucky at http://www.courier-journal.com/article/20081107/NEWS01/811070437/1008/rss01, November 7, 2008.
52. WLKY.com. PRP Football Player Collapses at Practice, In Critical Condition. http://www.wlky.com/sports/17267086/detail.html. August 22, 2008.
53. WLKY.com. PRP Football Player Dies 3 Days after Collapse in Practice. Louisville, Kentucky. At http://www.wlky.com/health/17280899/detail.html, August 27, 2009.
54. Binkley, Helen; Beckett, Joseph;Casa, Douglas; Kleiner, Douglas; Plummer, Paul. National Athletic Trainers’ Association Position Statement: Exertional Heat Illnesses. Journal of Athletic Training. 2002 Jul-Sep; 37(3): 329-343.
55. Parents’ and Coasches’ Guide to Dehydration and other Heat Illnesses in Children. National Safe Kids Campaign. Adapted from: Inter-Association task force on exertional heat illnesses consensus statement: National Athletic Trainers’ Association. June 2003. Available at: www.nata.org/industryresources/heatillnessconsensusstatement.pdf.
Prepared by Stephen T. Hougen, M.D., F.A.C.S., GETAC Injury Prevention Committee, August 19,
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THE SIGNS AND SYMPTOMS OF OVERUSE, OVER-TRAINING EXERCISE

Overuse Injury Signs and Symptoms
• Inflammation
• Tumor [Latin]- Swelling is the most common sign of an overuse injury. redness,
• Calor [L] - Warmth
• Dolor [L] - Pain with movement, pain to deep touch,
1. In the beginning, after practice or game
2. During practice or game
3. Persistent Pain, all the time
• Rubor [L] - Redness
• Rubbing. Grating sensation over the muscle. tendon, ligament or joint when it is moved.

One or more of these signs and symptoms might be present. At first, the signs and symptoms occur after practice. With progression of the overuse injury, the pain will occur during practice or games. Eventually, without proper treatment the signs and symptoms will persist at all times and the Athlete’s performance will be compromised.

Children and Youth are not lilttle adults and cannot be treated as such. Child and Youth Athletes are most risk for overuse injuries because their bones, joints, ligaments and tendons are in the process of growing and have not fully developed. Human growth and development continues into the early 20’s. Growth Plate development is at Risk.

Treatment
The best treatment is Prevention, but in the alternative .R.I.C.E. and proper medical consultation and treatment are necessary.

• Prevention is Key and the most important treatment. Coaches musst be able to recognize the Physical Limits of Athletes and not cross the line and cause overuse and over training injuries.

However, in the event overuse Injury Results the treatment follows:

R.I.C.E.
• Rest involves giving the injured tissue adequate time to repair itself. During periods of acute pain, athletes should consider a stop in play and allow time for the injury to heal.
• Ice is used to decrease inflammation and should be applied before and after practice or games over the injured body part.
• Compression involves applying an elastic wrap over the injured part to help reduce swelling.
• Elevation helps to decrease swelling by using gravity to assist in the process.

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen after consultation with the Trainer and Doctor are beneficial for healing.
________________________________________________________________

The Coach can yell and scream, push and punish until the cows come home, but more is not better. More exercise, repetition and conditioning will not help overcome the laws of nature for both male and female athletes: particularly where the female Athlete body is concerned i.e. anatomy (ectomorph, mesomorph, endomorph), female hormones and neuromuscular control.

Prolonged Anaerobic Metabolism (Exercise to Exhaustion) is self-defeating and damages tissue and cells beginning microscopically but ultimately it results in major neuromuscular and joint injuries. Controlling the intensity and duration of the sport participation activity is the secret to injury prevention.

“A literature review reveals that 30% to 50% of all sports injuries result from overuse. Overuse injuries occur when a tissue is injured due to repetitive submaximal loading. The process starts when repetitive activity fatigues a specific structure such as tendon or bone. With sufficient recovery, the tissue adapts to the demand and is able to undergo further loading without injury.

“Without adequate recovery, microtrauma develops and stimulates the body’s inflammatory response, causing the release of vasoactive substances, inflammatory cells, and enzymes that damage local tissue. Cumulative microtrauma from further repetitive activity ultimately causes clinical injury. In chronic or recurrent cases, continued loading produces degenerative changes leading to weakness, loss of flexibility, and chronic pain.

“Thus, in overuse injuries the problem is often not acute tissue inflammation, but chronic degeneration (ie, tendinosis instead of tendinitis).”
[Overuse Injuries in Children and Adolescents John P. DiFiori, MD THE PHYSICIAN AND SPORTSMEDICINE - VOL 27 - NO. 1 - JANUARY 1999]

Baquie and Bruckner recently reported that overuse injuries at their center during a 1-year period were twice as frequent as acute injuries, with the most common presentation being anterior knee pain. “An overuse injury occurs when repetitive microtrauma overloads the capacity of a tissue to repair itself. This may result in an inflammatory response leading to acute, and then possibly chronic, inflammation, ultimately resulting in structural changes in tissue. Overuse injuries have become an increasing problem in sports medicine in the past two decades as a result of a trend towards increased volume of training in all sports.” [Baquie and Bruckner BrJ Sports Med 1997;31:2-4 Overuse injuries: where to now? http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1332463/pdf/brjsmed00001-0010.pdf]

[BrJ Sports Med 1997;31:2-4 1 Baquie P, Brukner PD. Injuries presenting to an Australian sports medicine clinic. CGin J Sport Med (in press).

Bennell KL, Crossley K. Musculoskeletal injuries in track and field: incidence, distribution and risk factors. AustrJSci Med Sport 1996;28:69-75.

Bennell KL, Malcolm SA, Thomas SA, et al. The incidence and distribution of stress fracture in competition track and field athletes. A twelve month study. Am J Sports Med 1996;24:21 1-18.
Brukner P, Khan K. Clinical sports medicine. Sydney: McGraw Hill, 1993: 17.

Bennell KL, Malcolm SA, Thomas SA, et al. Risk factors for stress factors in track and field athletes. A twelve month prospective study. Am JT Sports Med (in press).

Dalton SE: Overuse injuries in adolescent athletes. Sports Med 1992;13(1):58-70

Herring SA, Nilson KL: Introduction to overuse injuries. Clin Sports Med 1987;6(2):225-239

Micheli LJ: Overuse injuries in children's sports: the growth factor. Orthop Clin North Am 1983;14(2):337-360

Gross ML, Flynn M, Sonzogni JJ: Overworked shoulders: managing injury of the proximal humeral physis. Phys Sportsmed 1994;22(3):81-86

Drinkwater BL, Nilson K, Chesnut CH III, et al: Bone mineral content of amenorrheic and eumenorrheic athletes. N Engl J Med 1984;311(5):277-281

Myburgh KH, Hutchins J, Fataar AB, et al: Low bone density is an etiologic factor for stress fractures in athletes. Ann Intern Med 1990;113(10):754-759

Ilahi OA, Kohl HW III: Lower extremity morphology and alignment and risk of overuse injury. Clin J Sport Med 1998;8(1):38-42

Gieck JH, Saliba EN: Application of modalities in overuse syndromes. Clin Sports Med 1987;6(2):427-466

Current comment from the American College of Sports Medicine: The prevention of sport injuries of children and adolescents. Med Sci Sports Exerc 1993;25(suppl 8):1-7

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Measuring Exercise Intensity Gin Miller.com

"There are several ways to measure your exercise intensity: target heart-rate checks, perceived exertion and talk test, and heart rate monitors, now increasing in popularity due to ease of use and relative accuracy.

For many years, measuring exercise intensity using the target heart-rate method and pulse check was the standard in group fitness and exercise videos. In more recent years, the easily-applied perceived exertion check and talk test has become more prevalent in both.

Today, heart rate monitors are becoming the new standard for goal-oriented and serious-minded exercise enthusiasts. Not only do they provide immediate and fairly accurate feedback but they can also track your progress and improvements in fitness over time.

The Target Heart Rate Method

The "Target Heart-Rate" is the level at which it is recommended to be working in order to challenge the cardio-respiratory system and to be working in the "training" or "aerobic" zone. Within this zone, your body burns a higher percentage of fat calories, therefore it is commonly referred to as the "fat burning zone". (However, research has shown that higher intensity training results in an increased overall caloric burn - see intensity training.)

If you are just getting started with cardiovascular exercise, it's a good to know your "normal" or beginning heart rate, which will help you monitor your overall gains in your cardiovascular fitness.

Prior to your exercise session, first check your normal activity heart-rate. After you have gradually increased the level of intensity in your work effort, you should check to see where you are working within your training zone. At the peak of your intensity effort, measure your heart rate, then as you decrease intensity back to normal, check your heart rate again. The amount of time from peak activity back to normal heart rate is your recovery time. By measuring how long it takes for you to recover will give you an idea of your improvement in cardiovascular fitness. The fitter you are, the faster your heart-rate will recover back to normal.

Calculating Target Heart Rate

The most prominent and accurate means of determining target heart-rate is the Karvonen formula. This formula calculates a percentage of the heart-rate reserve, which is the difference between the resting heart-rate and the maximal heart-rate.
Heart-rate reserve = maximal heart-rate - resting heart-rate

Maximal Heart-rate is the highest rate a person can attain during exercise. While an electrocardiogram test would provide the most accurate MHR, for practical application an age-predicted heart-rate formula was developed.

Maximal heart-rate = 220 - age

This formula is based on the assumption that one's heart rate at birth is 220 and decreases by one every year. The accuracy of determining maximal heart-rate based on this formula can vary at any given age by + 10 beats per minute.

Resting Heart-rate is the rate at which your heart beats at full rest. It is recommended that this rate be taken before getting out of bed, counting the pulse for a full 60 seconds, 3 mornings in a row and averaging the counts.
Determining the target heart-rate ranges:

Karvonen Formula

Using the Karvonen formula, the generally accepted heart-rate ranges are between 60% to 80% of maximal heart-rate reserve.
Target heart-rate = % intensity X heart-rate reserve + resting heart-rate
Here's how it would be calculated for a 45 year old with a resting heart-rate of 80 and an age-predicted maximal heart-rate of 175 at an 80% intensity level of maximum heart-rate reserve:

175 (age predicted MHR)
- 80 (resting heart-rate)
95 (heart rate reserve)
X.80 (intensity level)
76.00
+80.00 (resting heart-rate)
156.00 (target heart rate)

It is recommended that the formula be applied to both ends of the range, 60% and 80%, to determine the target heart-rate training zone.
The Karvonen formula is considered more accurate than the Maximal heart-rate formula, because the resting heart-rate is used in the calculation. From a practical standpoint, few people actually figure out an average for their true resting heart-rate.

Maximal Heart-Rate Formula

Therefore the simplified Maximal heart-rate formula is the standard that was used in most group exercise settings:

target heart-rate = maximal heart-rate (mhr) X % intensity
For the same 45 year old, here's how the range would be figured:
At 60 % Intensity -
175 (mhr: 220 - age)
X.60 (percent intensity)
105 (target Heart-rate)
At 80% Intensity -
175 (mhr: 220 - age)
X.80 (percent intensity)
140 (target heart-rate)

In group fitness settings, easy reference for intensity levels may be provided with a Target Heart Rate Chart. To view a sample of a heart-rate/age/intensity chart, click here.

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EXERCISE TO EXHAUSTION IN HEATED OZONE SOUP IS A RECIPE FOR CHILD ATHLETE DEATH FROM EXERTIONAL HEAT STROKE AND OZONE INTOXICATION
EXERCISE TO EXHAUSTION IN HEATED OZONE SOUP IS A RECIPE FOR CHILD ATHLETE DEATH FROM EXERTIONAL HEAT STROKE AND OZONE INTOXICATION
July 6, 2008 7/6/08:

Beijing Air Pollution Will Kill Several Olympic Athletes; US Trainer Takes Precautions; Olympians Wearing Masks? by Stephen Fox

http://www.opednews.com/articles/Beijing-Air-Pollution-Will-by-Stephen-Fox-080705-351.html

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EXETCISE TO EXHAUSTION

“The state of exhaustion is one that is a common occurrence in all forms of athletic performance. It is a description that is intended to reflect a final, often dramatic, result of one or more bodily processes on the brink of failure. Where there is exhaustion, there must be an extreme level of fatigue, to the point where relief must be sought by the athlete or a catastrophe will invariably follow.

Exhaustion is a term employed in three distinct contexts in sports science. Physical exhaustion is the expression used to describe either musculoskeletal fatigue or a general inability to physically continue to perform at the desired level due to all energy stores having been consumed. Physical exhaustion is most common in those sports where the activity occurs over a longer period of time, as in distance events of all types; it may also arise through prolonged training for shorter duration events.

Mental exhaustion is the loss of mental keenness. Mental fatigue can occur during an event, such as an endurance race, but more commonly this state occurs in a cumulative fashion, due to factors such as the pressure of high level competition or the stress imposed upon the athlete through daily training sessions. Terms such as “burnout,” “staleness,” and “brain-fog” are expressions of mental exhaustion. Heat exhaustion is a subset of physical exhaustion, but as it arises in specific environmental circumstances, it has a separate and well-developed set of physical indicators.

Physical exhaustion is a condition that is most commonly revealed by extreme fatigue on the part of athletes, where they are no longer physically capable of performing at their accustomed level. As physical exhaustion typically occurs in endurance sports, it is the aerobic energy system that is central to an examination of the mechanics of this condition. When the body requires energy for activities lasting longer than approximately 90 seconds, it will fuel itself through the production of the energy source adenosine triphosphate (ATP), using available stores of glucose.

ATP is produced as the culmination of a process whereby the bodily carbohydrate stores, glycogen, are converted to glucose and transported through the red blood cells of the bloodstream to the muscles where the ATP conversion occurs. The red blood cells also transport the oxygen required to metabolize, or burn, this fuel; the blood also removes the waste products and carbon dioxide produced in this process.

The simplest and most common form of physical fatigue is when the body simply runs out of the primary sources of carbohydrate required to manufacture energy in the form of ATP. When the body determines that it has no more glycogen available to it (the liver regulates the level of these sugars present in the bloodstream), it will revert to the consumption of stored fats to convert into energy sources.

Fats are a comparatively lesser, more inefficient fuel for energy production. As with any machine, when the fuel sources are spent, the body cannot continue to perform.
An inability to produce energy does not only affect the muscles and other working components of the body, but also the functioning of the brain and the central nervous system; a depletion of physical energy stores will cause significant reductions in concentration and mental function.

Absent any other physical factors contributing to the physical exhaustion, such as extreme cold or altitude, this circumstance will be corrected through rest and the ingestion of appropriate carbohydrate-rich foods to redress the bodily balance.

The other most common potential causes of physical exhaustion in an athlete, occurring either singly or in combination with other factors, include: illness (such as cancer); poor long-term nutritional habits (such as lacking vitamins or minerals necessary to the function of the energy systems); mental stress; environmental condition (e.g., air pollution); and dehydration (when the fluid level of the body is reduced, the volume of fluid in the bloodstream is correspondingly less).

Physical exhaustion is also an expression used to describe the testing processes used to calculate performance measures such as VO2max, the maximum amount of oxygen that an athlete can process, which is a powerful indicator of endurance sport fitness.

Physical exhaustion is also the stated limit to carbohydrate depletion tests and interval training of all types. The immediate, short-term athletic goal in each of these mechanisms is to train to physical exhaustion; the long-term objective is to extend the prior physical limits.

Mental exhaustion can arise in a number of circumstances in relation to both training and competitive circumstances. Professional team sport athletes who are required to play a number of games over a period of weeks will often complain of a lethargy and lack of motivation. Hard training, especially when the individual components are repetitive, can occasionally result in a similar mental fatigue.

Heat exhaustion a progression in the overheating of the body known as hyperthermia. When the body is working, especially in warm or humid conditions, it cools itself by forcing warm blood to the surface of the skin, which results in the production of perspiration, which in turn both dehydrates the system and depletes the body of the mineral sodium.

The symptoms of heat exhaustion are severe thirst, generalized weakness, and a loss of coordination (due to reduced mineral levels, which aid in the transmission of nerve impulses to the muscles). The next stage in this progressive heat illness is a heat stroke, which may result in cardiac arrest and death. A notable fatality due to heat stroke was that of Korey Stringer, National Football League (NFL) lineman, in 2001 during a hot weather training camp session.”

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Vo2 Max

"An athlete's exercise effort is best clinically measured by Vo2 Max. This measure will tell you the given physiological effort exerted during exercise. However, in a practical setting exercise effort is harder to define. Many coaches and athletic trainers will use heart rate as the measure of exertion in such a setting. This however will only measure effort for a specified time of exertion and not over the course of time or training."

"Over exercise/training is not at all easy to measure objective. Research in this area has tried to define several characteristics that can explain when a person has passed threshold of exercise. This is typically referred to as overtraining syndrome. It is best diagnosed through a variety of factors most of which are relatively subjective rather than objective. The measure used to define it in high level athletes are usually; fatigue outside of exercise, decreased performance, fatigue during simple exercise, decreased interest in the activity, decreased ferritin lab values, decreased Vo2 Max and increased rates of injuries and/or muscle soreness. As you can see overtraining syndrome is not easy to diagnose. Most commonly athletic trainers and physicians will go by injury rates, ferritin lab values and performance indicators."
[Amy Waugh, certified athletic trainer, University of Kentucky Department of Orthopaedics and Sports Medicine]

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If deaths continue a futuristic football helmet might have an RFID-enabled football helmet that prevents heatstroke by measuring body temperature and a monitor that measures the target heart-rate and pulse check to prevent over exercise/training. Both would be wirelessly transmitted to the sideline traineer who moniters the measurements. Measuring exercise intensity attempts to define the threshold of exercise tolerance and over training syndrome. Increased rates of injuries and/or muscle soreness are indicators of course. Objective laboratory findings are decreased ferritin lab values and decreased Vo2 Max. These are performance indicators, but not as practical as target heart-rate and pulse check in the helmet.
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ACUTE RHABDOMYOLYSIS

Acute Rhabdomyolysis is suggested by the history of recent and past events and the physical examination. It is confirmed by blood and urine testing. An important part of diagnosing rhabdomyolysis is a comprehensive medical history and physical examination.

The medical history may include questions about any medication use, drug and alcohol use, other medical conditions, any trauma or accident, etc. Blood tests include a complete blood count (CBC), a metabolic panel, muscle enzymes, and urinalysis.

The diagnosis of rhabdomyolysis is confirmed by detecting elevated muscle enzymes in blood. Muscle enzymes include creatine phosphokinase (CPK), SGOT, SGPT, and LDH. The levels of these enzymes rise as the muscle is destroyed in rhabdomyolysis.
Of note, CPK is also in heart muscle (cardiac muscle) and brain. The laboratory is usually able to distinguish between the different components of this enzyme. For example, the fraction coming from skeletal muscle is referred to as CK-MM and the one from heart muscle is designated as CK-MB. There are small amounts of the CK-MB component in the skeletal muscle as well.

The levels of myoglobin can be elevated in blood and urine

SGOT: Serum glutamic oxaloacetic transaminase, an enzyme that is normally present in liver and heart cells. SGOT is released into blood when the liver or heart is damaged. The blood SGOT levels are thus elevated with liver damage (for example, from viral hepatitis) or with an insult to the heart (for example, from a heart attack). Some medications can also raise SGOT levels. SGOT is also called aspartate aminotransferase (AST).

SGPT: Serum glutamic pyruvic transaminase, an enzyme that is normally present in liver and heart cells. SGPT is released into blood when the liver or heart are damaged. The blood SGPT levels are thus elevated with liver damage (for example, from viral hepatitis) or with an insult to the heart (for example, from a heart attack). Some medications can also raise SGPT levels. Also called alanine aminotransferase (ALT).
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CDC October 26, 1990 / 39(42);751-756, Morbidity and Mortality Weekly Report Centers for Disease Control and Prevention, 1600 Clifton Rd, MailStop E-90, Atlanta, GA 30333, U.S.A

Exertional Rhabdomyolysis and Acute Renal Impairment — New York City and Massachusetts, 1988

During the summer and fall of 1988, outbreaks of exertional rhabdomyolysis (the breakdown of muscle fiber) with renal impairment occurred in New York and Massachusetts among candidates or trainees for public safety positions. In each of the outbreaks, risk for illness was lower in persons who were accustomed to vigorous exercise; however, incidence rates, the relation to dehydration, and settings differed.New York

On June 14, 1988, the New York City (NYC) Department of Health was notified of one death and three hospitalizations among candidates for the NYC Fire Department (NYCFD) who had taken the NYCFD competitive physical fitness test within the previous 2 weeks. The fatality occurred in a young man with sickle cell trait who died because of uncontrollable hyperkalemia secondary to rhabdomyolysis within 6 hours of taking the fitness test; the three other hospitalized candidates had rhabdomyolysis and renal insufficiency.

The firefighter physical fitness test is usually administered during a 2- to 3-month period every 4 years to approximately 25,000-30,000 men and women who are aged 19-29 years and who have passed the NYCFD written employment examination. The test, which was given indoors in a temperature-controlled environment, required the candidates to wear a 20-lb vest and a 20-lb oxygen tank while consecutively performing 11 activities that simulate typical firefighter tasks. Completion of the test in less than or equal to 7 minutes earned a passing score, and completion in less than or equal to 4 minutes earned a 100% score.

Following the hospitalizations, the test was suspended on June 15 and resumed on June 27 with modified pre- and post-testing procedures. However, additional hospitalizations occurred, and on July 13, the test was again suspended. In late July, an epidemiologic investigation was initiated; the investigation included an environ mental evaluation for carbon monoxide, which did not reveal elevated levels inside the building. Testing was temporarily suspended four times during the 19 months (May 31, 1988-December 21, 1989) after it was initiated. Each suspension was followed by an evaluation of the test by medical experts and exercise physiologists.
On June 27, a series of interventions was implemented to prevent exertional rhabdomyolysis by minimizing the effect of the ambient temperature, screening out candidates with current or prior medical problems, and assuring adequate hydration. Specific interventions included cancelling the test during the summer, requiring medical clearance from a physician, instructing candidates to reschedule the test if they were ill, urging candidates to avoid all medication and alcohol for 24 hours before and after the test, and providing fluids before the test. Despite these interventions, cases of rhabdomyolysis and/or renal impairment requiring hospitalization occurred during each of the five testing periods.

During the 19-month period, 32 (0.2%) of 16,506 candidates were hospitalized for rhabdomyolysis and/or acute renal impairment after taking the fitness test; 41 other candidates were treated in emergency rooms but not admitted to hospitals. Of those hospitalized, four had rhabdomyolysis (defined as a serum creatinine phosphokinase (CPK) greater than or equal to 600 U/L (normal: 60-200 U/L)), and 16 had renal impairment (defined as serum creatinine greater than or equal to 3.0 mg divided by L (normal: 0.6-1.3 mg divided by L)); 12 had both rhabdomyolysis and renal impairment.

Thirty (94%) of the 32 hospitalized candidates presented with back pain, 26 (81%) with nausea and vomiting, 20 (63%) with abdominal pain, 18 (56%) with muscle pain, and 18 (56%) with decreased urine output; four required hemodialysis. The mean hospital stay was 6 days (range: 1-20 days). All hospitalized candidates were men. None of the 84 women candidates reported illness. The mean age of the patients was 25 years; 29 were white, two were black, and one was Hispanic.

After the second testing period, the NYC Department of Health and CDC conducted a case-control study using patients from the first two testing periods to assess potential risk factors. Thirteen of the 18 patients whose illnesses occurred in the first two periods agreed to be interviewed. Of the candidates who took the test during the same period and were not affected, 161 were selected randomly to serve as controls; 108 (67%) agreed to a telephone interview.

The risk for rhabdomyolysis and/or acute renal impairment after taking the test was increased in candidates with an underlying medical condition (e.g., pneumonia or renal vein thrombosis) (odds ratio (OR)=10.3; 95% confidence interval (CI)=2.5-43.6). The risk was lower for men who engaged in physical activity (work plus leisure activity greater than or equal to 50 hours per week; OR=0.2; 95% CI=0.1-0.9). Risk for illness was not associated with the test score.

Based on the epidemiologic and clinical data and the failure of the implemented interventions, the NYC Department of Health recommended that the test be modified before it is given again and a comprehensive survey be done of alternative methods of selecting firefighter candidates in other cities.Massachusetts

On September 19, 1988, 50 police trainees from local police departments began a 14-week “mental stress” and physical training program at a state-sponsored academy in western Massachusetts. On the evening of September 21, the Massachusetts Department of Public Health was notified that five trainees had been hospitalized.

The program was suspended, and an epidemiologic investigation initiated September 22 determined that some trainees had experienced severe dehydration, rhabdomyolysis, and/or acute renal insufficiency. An environmental investigation did not identify any biological agents in the air or water.

All trainees were white; most were young adults (mean age: 25 years) and male (94%). The first 3 days of the training program were physically strenuous and included push-ups, squat-thrusts, and running. Daytime temperatures were 75-80 F (24-27 C), with a relative humidity of 50% (apparent temperature (heat index): 75-80 F (24-27 C)). During the training program, drinking water was available only during three or four short breaks each day; trainees obtained water from a 19-L (5-gal) water cooler using 90-mL (3-oz) fold-out cups and from faucets in the restrooms by hand scooping. The amount of water drunk by each trainee could not be quantified; however, based on the known limited availability of water, as well as reports of severe thirst and the large volumes of fluids drunk at the end of each day (compensatory hydration), water intake was considered to be grossly inadequate.

All 50 trainees had evidence of rhabdomyolysis (serum CPK greater than or equal to 10 times normal) and 33 (66%) had severe rhabdomyolysis (serum CPK greater than or equal to 200 times normal). Thirteen (26%) of the trainees were hospitalized with complaints of nausea, back and abdominal pain, and dark urine; each of those hospitalized had serum CPK levels greater than or equal to 32,000 U/L (normal: 10-300 U/L) and an abnormal urinalysis. Nine (69%) of those hospitalized had evidence of renal insufficiency (serum creatinine greater than or equal to 2.0 mg divided by L); six (46%) required hemodialysis. One trainee died 44 days after onset from complications of heat stroke, rhabdomyolysis, and renal and hepatic failure.

One month before the program, 49 of the trainees were tested for cardiovascular fitness (2.4-km (1.5-mile) run) and muscular strength (sit-ups). Compared with trainees who passed both tests, those who failed either test were at increased risk for severe rhabdomyolysis (relative risk (RR)=2.5; 95% CI=1.3-4.9) or renal insufficiency (RR=2.0; 95% CI=0.5-8.8).

As a result of this investigation, the Massachusetts Criminal Justice Training Council extensively revised its police training program. “Mental stress” training, including the use of physical exercise as a punishment for infractions, was immediately abolished. An exercise physiologist who was appointed to develop a physical fitness regimen recommended requirements for 1) meeting specific physical fitness and medical standards before and during the training program; 2) adequate hydration during activity, based on the intensity and duration of the activity and prevailing environmental conditions; and 3) a clear administrative chain of responsibility and protocol for responding to injury or illness. Reported by: A Goodman, MD, S Klitzman, DrPH, S Lau, MPH, IW Surick, MD, S Schultz, MD, W Myers, MD, New York City Dept of Health. J Dawson, MD, Div of Critical Care, Bay State Medical Center, Springfield; JE Smith, Jr, Massachusetts Criminal Justice Training Council, RJ Timperi, MPH, GF Grady, MD, State Epidemiologist, Massachusetts Dept of Public Health. Div of Surveillance, Hazard Evaluation, and Field Studies, National Institute for Occupational Safety and Health; Div of Field Svcs, Epidemiology Program Office; Div of Chronic Disease Control and Community Intervention, Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: Rhabdomyolysis is a natural consequence of vigorous physical activity.

In persons unaccustomed to regular physical activity, rhabdomyolysis may be extensive, and renal impairment may occur, especially when dehydration or acidosis are also present (1). Dehydration alone can also cause impaired renal function by decreasing renal perfusion. These problems have been recognized among military personnel, long-distance runners, and other athletes (2-6). However, exercise-related rhabdomyolysis and renal impairment have not been previously described in the groups involved in this report.

The circumstances in Massachusetts resemble those in military recruit training programs (i.e., young men of varying levels of physical fitness who begin sustained strenuous exercise in moderately warm outdoor conditions). In contrast, the outbreak in the NYC firefighter candidates was associated with an indoor temperature-controlled environment, and the exercise was brief (less than or equal to 7 minutes) in duration. Only one other outbreak of exertional rhabdomyolysis has been reported following a short exercise period ( less than 10 minutes) in an indoor setting (4).

In Massachusetts, neither the ambient temperature nor humidity were markedly elevated (apparent temperature: 75-80 F (24-27 C)). Thus, the outbreak underscores the need to assure adequate hydration during exercise regardless of the temperature. Exercise physiologists recommend that, in addition to normal water replacement, an additional 250 mL of fluids is needed for every 15-20 minutes of exercise (7). Based on ambient dry bulb temperatures and relative humidity (Figure 1), nomograms have been developed to aid participants and persons responsible for groups involved in exercise during warm weather. Special efforts to assure hydration may be necessary when the apparent temperature approaches 80 F (27 C).

The substantial difference in the hospitalization rates in NYC (0.2%) and Massachusetts (26%) probably reflects a variety of factors, including environmental conditions and types of exercise. In both outbreaks, however, level of physical fitness appeared to influence the risk for illness. High levels of physical fitness may be protective through increased muscle conditioning, accelerated heat acclimatization, and reduction of postexertional myoglobinemia (2,8-10). Thus, findings from both outbreaks support the general recommendation that persons who plan to engage in extreme muscle exertion should first participate in a preconditioning program to improve their physical fitness.

Although the NYC investigation suggested that having an acute and/or chronic medical condition placed candidates at a higher risk for rhabdomyolysis and/or renal impairment, these findings should be interpreted with caution because case-patients may have been more likely than controls to report illness; consequently, their underlying conditions were more likely to be detected through medical record review. Certain conditions (e.g., viral illnesses, cocaine and aspirin abuse, and prior history of heat exhaustion) increase the risk for rhabdomyolysis and/or renal impairment (1,11).

Sickle cell trait has been associated with an increased risk for sudden death during exertion (12). However, the absolute risk for sudden death is low, and persons with sickle cell trait should not be excluded, on that basis alone, from employment requiring maximal physical exertion (13). Based on this investigation and others (1,11), persons with infectious diseases should be advised to postpone testing until their illness has resolved; those with metabolic abnormalities should participate only with medical supervision; those with substance-abuse problems should be referred for appropriate treatment.

In NYC, the increasing risk for illness despite successive implementation of preventive measures suggests that the effectiveness of case-finding improved and that severe rhabdomyolysis and renal impairment among participants in similar programs might occur more frequently than previously suspected. The increasing risk also suggests that the preventive measures could have been inadequate. Prior studies suggested that the measures were appropriate; however, those studies (1-7) were of persons engaged in exertion of much longer duration than the NYCFD candidates. The effect of measures to reduce or prevent exertional phenomena after short-duration activities needs to be clarified.

In the United States, there are an estimated 800,000 police officers (14) and 203,000 paid and 500,000 volunteer firefighters (Federal Emergency Management Agency, National Fire Academy, unpublished data, 1989). Among these workers, fitness testing is used increasingly as a criterion for job entry and for job retention (International Association of Fire-Fighters, personal communication, 1989). The need for physical performance testing must be balanced carefully with the safety of persons participating in the testing; the National Fire Protection Association (NFPA) is developing new standards for fitness testing of firefighters. Physicians and other providers who monitor the health of these persons or who serve as occupational health consultants to fire and police departments, their unions, training academies, or advisory groups (e.g., the NFPA) should be aware of these potential problems.

References
1. Gabow PA, Kaeny SP. The spectrum of rhabdomyolysis. Medicine
1982;61:141-52.
2. Demos MA, Gitin EL. Exertional myoglobinemia and acute rhabdomyolysis. Arch Intern Med 1974;134:669-73.
3. Schrier RW, Henderson HS, Tisher CC. Nephropathy associated with heat stress and exercise. Ann Intern Med 1967;317:356-76.
4. Hamilton RW, Gardner LB, Penn AS. Acute tubular necrosis caused by exercise-induced myoglobinuria. Ann Intern Med 1972;77:77-82.
5. Howenstine JA. Exertion-induced myoglobinuria and hemoglobinuria. JAMA 1960;173:493-9.
6. Demos MA, Gitin DL. The incidence of myoglobinuria and exertional rhabdomyolysis in marine recruits. Camp Lejeune, North Carolina: The Naval Medical Field Research Laboratory, 1973;23:1-5.
7. Costill DL. Gastric emptying of fluids during exercise. In: Gisolfi CV, Lamb DR, eds. Perspectives in exercise science and sports medicine. Vol 3. Fluid homeostasis during exercise. Carmel, Indiana: Benchmark Press, 1990:97-121.
8. Olerud JE, Homer LD, Carroll HW. Incidence of acute exertional rhabdomyolysis. Arch Intern Med 1976;136:692-7.
9. Gisolfi C, Robinson S. Relations between physical training, acclimatization, and heat tolerance. J Appl Physiol 1969;26:530-4. 10. Gavhed DC, Holmer I. Thermoregulatory responses of firemen to exercise in the heat. Eur J Appl Physiol 1989;59:115-22. 11. Roth D, Alarcon FJ, Fernandez JA, et al. Acute rhabdomyolysis associated with cocaine intoxication. N Engl J Med 1988;319:673-7. 12. Kark JA, Posey DM, Schumacher HR, Ruehle CJ. Sickle cell trait as a risk factor for sudden death in physical training. N Engl J Med 1987;317:781-7. 13. Sullivan LW. The risks of sickle cell trait: caution and common sense. N Engl J Med 1987;317:830-1.14. Bureau of Justice Statistics. Profile of state and local law enforcement agencies, 1987. Washington, DC: US Department of Justice, Bureau of Justice Statistics, 1989; publication no. NCJ-113949.

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The following is he most excellent published rewponse and investigation to a Rhabdomyolysis Epidemic. Excellent investigation by Dr. Katrina Hedberg, MD, MPH

Heat, Dehydration Factors In McMinnville Injuries
1st POSTED: 11:54 am PDT September 2, 2010

http://www.oregon.gov/DHS/ph/ipe/docs/OPHD_Football_Prelim_Report.pdf

PORTLAND, Ore. — State health officials investigating muscle injuries suffered by 24 members of the McMinnville High School football team said intense exercise, heat and dehydration were factors in the illness, while tests for chemical supplements came back inconclusive.

“There is not one factor that we can pinpoint as the cause. Rather, it appears that multiple factors including the type of exercise, the hot day and not enough water for some of the players contributed to their illnesses,” said Katrina Hedberg, Oregon state epidemiologist.

The injuries stemmed from a preseason workout on Aug. 15 with the team’s new coach, Jeff Kearin, in a hot wrestling room.

Of the 43 football players participating in the camp, three needed surgery for compartment syndrome, a type of painful muscle swelling.

Five others suffered from rhabdomyolysis, a muscle injury that can lead to kidney failure, in addition to elevated muscle enzymes signifying injury. Fourteen additional players had muscle pain with and elevated enzyme levels, health officials said.
The hospitalized players denied taking supplements that could have contributed to the injuries. Oregon Department of Human Services officials said blood tests for creatine levels were inconclusive because the tests don’t discern between supplemental creatine and naturally occurring levels.

The last player was released from the hospital Aug. 24.

An inspection of the McMinnville High School gym and wrestling room didn’t reveal any problems with water quality, carbon monoxide or other problems that could have sparked the injuries.

Food-borne illnesses were also ruled out as possible factors, health officials said.
A team of several epidemiologists began the investigation Aug. 23. They recommended coaches and school officials keep in mind that intense, repetitive exercise focusing on single muscle groups can cause injury. They also said coaches need to constantly assess players’ health and adjust workouts accordingly.

Despite the injuries, McMinnville High School will start its football season on schedule with a game against Sam Barlow High School at 7 p.m. Friday in Gresham.

Preliminary Report:
Cluster of Compartment Syndrome and Rhabdomyolysis Among McMinnville High School Football Team
Katrina Hedberg, MD, MPH
State Epidemiologist
Oregon Public Health Division
2 September 2010 2

Summary

On 23 Aug 2010, the Oregon Public Health Division (OPHD), in coordination with Yamhill County Health Department, began investigating a cluster of triceps compartment syndrome and rhabdomyolysis among McMinnville High School football team members with onset of illness during the previous week. (Compartment syndrome, typically resulting from muscle injury, is characterized by abnormally high pressures in an enclosed muscle compartment that impedes adequate blood circulation; it is a surgical emergency.

Rhabdomyolysis is muscle injury that can lead to kidney failure and death.) OPHD investigated this cluster in order to: 1) confirm the diagnoses and spectrum of illnesses; 2) identify contributing factors leading to illnesses; 3) derive information to help ensure the safety of participants in organized sports and prevent similar illnesses from recurring. Oregon Administrative Rule 333-018-0015 authorizes OPHD to conduct public health investigations of any “uncommon illness of potential public health significance”. This preliminary report summarizes the OPHD investigation as of 2 Sep 2010.

OPHD conducted interviews with team members, coaches, school administrators, hospital administrators, and physicians; and reviewed the hospital medical records for all team members cared for at Willamette Valley Medical Center (WVMC).

OPHD also systematically assessed symptoms, exposures, and activities among team members. Following several hospitalizations of team members from 17-19 Aug 2010, WVMC offered creatine kinase (CK) testing (a blood test marker of muscle injury) of all team members on 19-20 Aug 2010 at McMinnville High School.

Among 43 team members participating in the varsity “immersion” football camp held the week 15 Aug 2010, 3 had triceps compartment syndrome, defined as a team member clinically diagnosed with this condition and treated with surgery, an additional 5 had rhabdomyolysis with muscle pain and CK > 23,200 U/L (100 times the upper limit of normal for WVMC laboratory), and 14 others had rhabdomyolysis with muscle pain and CK between 2,320 U/L (10 times the upper limit of normal) and 23,200 U/L. Of the 22 team members with triceps compartment syndrome and/or rhabdomyolysis, all 3 had muscle-related symptoms referable to the upper arm, 12 were hospitalized, and none had kidney failure. CK testing at McMinnville High School identified 16 of the 22 cases.

OPHD reviewed an upper arm exercise held on 15 Aug 2010 at approximately 1600 PDT in the high school wrestling room. The “team building” exercise involved repetitive, intensive, alternating chair dips and push ups for an estimated 4-5 minutes. It had been used by the head coach with previous teams dating back to 2003 without incident. Team members characterized this exercise as challenging but within the boundaries of pre-season conditioning. The temperature in the non-air conditioned wrestling room was not measured at the time of the exercise drill; however, the temperature recorded at McMinnville Municipal Airport at 1553 PDT was 92°F. While water was available and coaches encouraged consumption during the camp, most team members did not consume water during the exercises in the wrestling room.

Team members did not report use of illicit or performance enhancing drugs. Serum creatine levels, which do not distinguish creatine supplementation from dietary or endogenous creatine, were inconclusive. On preliminary review, OPHD did not find patterns suggesting an association with illness from specific prescription medications or nutritional supplements. Facilities assessment did not find any evidence that other environmental factors, including water quality, carbon monoxide, or volatile organic compounds, contributed to the illnesses. There was no evidence that infections or contaminated food or drinks were associated with illness.

OPHD concluded that multiple factors likely contributed to the cluster of triceps compartment syndrome and rhabdomyolysis, foremost among them an intense, short-duration, repetitive burst of resistance exercise on Sun 15 Aug 2010 that focused on a single muscle compartment. Additional contributing factors included environmental stress from heat and unrecognized dehydration.

Based on this preliminary report, OPHD recommends that: 4

1. Oregon coaches, trainers, school administrators, health professionals, parents, and recreational athletes recognize that intense, short-duration, repetitive resistance exercise involving a single muscle compartment can lead to serious health complications, particularly during exercise conditions with higher risk of heat stress and inadequate hydration.

2. Both during and outside of official sports seasons, Oregon coaches, trainers, and school administrators routinely and explicitly assess potential health and safety hazards to student-athletes, and implement appropriate countermeasures as warranted, such as activity modification, rest breaks, and hydration. 5

Background

On Monday, 23 Aug 2010, in coordination with Yamhill County Health Department, OPHD began investigation of a cluster of triceps compartment syndrome and rhabdomyolysis among McMinnville High School football team members with onset of illness the previous week.

OPHD investigated this cluster in order to:

1) confirm the diagnoses and spectrum of illnesses,
2) identify contributing factors leading to illnesses,
3) derive information to help ensure the safety of participants in organized sports and prevent similar illnesses from recurring.

Oregon Administrative Rule 333-018-0015 authorizes OPHD to conduct public health investigations of any “uncommon illness of potential public health significance”.
This preliminary report summarizes the OPHD investigation as of 2 Sep 2010.

OPHD Investigational Methods

The OPHD field investigative team visited WVMC and/or McMinnville High School on 23, 24, 27, and 29 Aug 2010. An OPHD industrial hygienist augmented the team on a site visit of the school facilities on 27 Aug 2010, and recorded real-time measurements of carbon monoxide, carbon dioxide, and volatile organic compounds (VOCs).

OPHD reviewed the hospital medical records for all football team members who were hospitalized and/or seen in the emergency department, focusing on physician notes, laboratory results, and clinical outcomes. In addition, OPHD reviewed the CK results for all team members who underwent testing on 19-20 Aug 2010. OPHD held phone or in-person interviews with selected physicians involved in care of the team members, including the two orthopedists who performed the operations and the hospitalist/football team physician involved in the inpatient management of many of the hospitalized 6 team members. At least 7 WVMC medical staff contributed to admission or emergency department examinations.

Meetings and interviews were held with WVMC administrators, McMinnville School District superintendent, high school principal, athletic director, facilities director, football coaching staff, and team members. OSAA provided information on heat index rules. OPHD was also invited to a football parents meeting on 24 Aug 2010 that involved a question-and-answer session with three Oregon physicians from outside Yamhill County with expertise in sports medicine and nutrition. During and after this meeting, OPHD addressed team member parents’ questions and concerns.

OPHD developed a standardized questionnaire that systematically assessed symptoms, exposures, and activities; attempts were made to interview all team members by phone or in person. Phone interviews with student-athletes commenced 26 Aug 2010. To increase the number of respondents, with the permission of the head coach, two OPHD epidemiologists conducted in-person interviews concurrent with team film study on 29 Aug 2010. All interviews were conducted privately.

Student-athletes and parents were instructed that individual responses were confidential, non-attributional, and not reportable to school, parental, and legal authorities. As of 2 Sep 2010, questionnaires were completed by 40 of 43 team members.

Summary of Events at McMinnville High School Football Camp – Sun 15 Aug 2010 – Fri 20 Aug 2010

Source: Interviews with coaching staff and team members; temperature data at McMinnville from National Weather Service (McMinnville Municipal Airport, elev. 157 ft.)

Sun 15 Aug 2010 – Beginning of football “immersion” camp at McMinnville High School. The overnight camp was restricted to 10th, 11th, and 12th grade football team members. After the team dropped off personal items in White Gymnasium (sleeping quarters for the camp), team members warmed up on the football field and completed several timed sprints. At approximately 1600 PDT, the team moved to the 7 indoor wrestling room to perform an exercise drill that the head coach had used numerous times with previous teams. The intent of the drill, as described by the head coach, was primarily to build team unity and accountability to other team members.

None of the assistant coaches had prior experience with this drill. Team members voluntarily picked partners for the exercise drill. The first exercise was described as a chair dip/push up exercise. The first partner, with second partner spotting, performed chair dips using the folding chair as support for 30 seconds, immediately followed by pushups for 30 seconds. This sequence was repeated in consecutively shorter intervals: 20 seconds, 10 seconds, 7 seconds, 5 seconds, with no scheduled rest periods. For incorrect performance by any team member, the exercise was suspended and then re-started by all team members at the beginning of the exercise component and time interval that team members had been engaged in at the time of suspension. The spotting partner was responsible for providing support for muscle fatigue and assist in both the concentric and eccentric phases of muscle contraction.

The targeted muscles during the drill were the triceps, pectoralis major, and deltoids. After the first group completed the exercise, the roles were switched. The exercise, without transition time, lasts 144 seconds. The actual estimated time for one partner to complete the exercise, including transition time and repeated interval times, was approximately 4-5 minutes. The second exercise focused on abdominal and leg muscles, and incorporated a similar timed format. The total amount of time in the wrestling room was estimated as 20-25 minutes. Team members characterized the arm exercise as challenging but within the boundaries of pre-season conditioning.

Water was available and consumption encouraged by coaches throughout the camp, but most team members did not consume water while they were in the wrestling room. The temperature in the non-air conditioned wrestling room that day was not available; the temperature in McMinnville at 1553 PDT was 92°F. Team members slept at home. High/Low temperature: 94°F/53°F. 8

Mon 16 Aug 2010 – 2nd day of football camp. Practices were held throughout the day, with conditioning work in the form of sprints held in the evening. Team members began to sleep at the high school gymnasium that night. High/Low temperature: 94°F/54°F.

Tue 17 Aug 2010 – An assistant coach transported a team member with arm pain and swelling to a physician appointment. The first case of compartment syndrome was diagnosed. A light weightlifting session was held in the morning. Practices were again held throughout the day. No conditioning drills were reported. High/Low temperature: 88°F/57°F.

Wed 18 Aug 2010 – Five more team members were hospitalized, including 2 additional cases of compartment syndrome. In the evening, the remainder of team was briefly screened for compartment syndrome at the high school by one of the treating WVMC orthopedists. No additional suspect compartment syndrome was identified. High/Low temperature: 76°F/50°F.

Thu 19 Aug 2010 – No outdoor or indoor exercise drills were held. WVMC sponsored voluntary CK testing of all team members in the evening; 28 team members underwent testing.

Fri 20 Aug 2010 – An additional 6 team members and 5 coaches underwent CK testing. Parents were notified of CK results. Team members with CK > 3000 U/L were advised to seek emergency care at WVMC. This led to 6 additional hospitalizations, and 10 other team members seen in the WVMC emergency department only. Football camp closed on 20 Aug 2010, one day prior to scheduled conclusion.

Findings of OPHD Investigation:

Description of Cases:

Among 43 team members participating in the varsity “immersion” football camp held the week 15 Aug 2010, 3 had triceps compartment syndrome, 5 others had rhabdomyolysis with CK > 23,200 U/L (100 times the upper limit of normal for WVMC laboratory), and 14 others had rhabdomyolysis with CK 9 betweeen 2,320 U/L (10 times the upper limit of normal) and 23,200 U/L. Of the 22 team members with triceps compartment syndrome and/or rhabdomyolysis, all had muscle-related symptoms referable to the upper arm, 12 were hospitalized, and none had kidney failure. CK testing at McMinnville High School identified 16 of the 22 cases.

Toxicology data:

Team members did not report use of illicit or performance enhancing drugs. Urine toxicology testing was not done during hospitalization and emergency department evaluation. Serum creatine levels, which do not distinguish creatine supplementation from dietary or endogenous creatine, were inconclusive. On preliminary review, OPHD did not find patterns suggesting an association with illness from specific prescription medications or nutritional supplements.

Potential environmental sources of illness:

OPHD investigated school facilities, including the gymnasium, wrestling room, football field, school locker room, cafeteria, and food court. Several persons questioned whether environmental factors may have contributed to illness, including water, sewer work, mold, and floor finishing products. An OPHD industrial hygienist accompanied the investigative team on 27 Aug 2010 (high temperature that day was 76°F) and toured the facilities. Real-time measurements were taken for carbon monoxide, carbon dioxide, and volatile organic compounds (VOCs). VOC samples addressed concerns that White gymnasium had an offensive chemical smell attributed to recent refinishing. All VOC samples were non-detectable. In addition, there was no source of VOCs identified. There was no carbon monoxide present in any area.

Carbon dioxide (CO2) samples were taken as a surrogate indicator of adequate ventilation; excessive CO2 levels can indicate a lack of fresh air. All CO2 levels were below 400 ppm, including background levels that were taken outside. The OPHD investigators noted that the wrestling room seemed less ventilated than other indoor areas visited.

Other causes of rhabdomyolysis: 10

Through medical record review and interviews, OPHD did not find trauma, genetic defects, infections, and metabolic or electrolyte derangements contributed to this cluster of rhabdomyolysis.

Other findings of significance:

Compliance with OSAA rules pertaining to heat index calculation, recordkeeping, and practice restrictions was not mandatory during the football immersion camp. These rules were enforceable to OSAA member schools beginning on 23 Aug 2010, the first official day of high school football practice. Prior to 23 Aug 2010, McMinnville High School athletics did not record the heat index, which is typically done by a school athletic trainer during the official season.

The heat index on 15 Aug 2010, based on conditions at 1553 PDT (temperature of 92°F, dew point of 59°F, relative humidity of 33%) was 91°F. For heat index < 95°F, OSAA recommendations include: “maximum of 5 hours of practice today, provide ample amounts of water, water should always be available and athletes should be able take in as much water as they desire, watch/monitor athletes for necessary action.” The short duration of team exercises that day, comprising two timed sprints on the football field followed by the resistance exercises in the wrestling room, were not considered high operational risk for heat-related illness. No specific safety briefings on Sun 15 Aug 2010 addressing heat were reported by the coaching staff.

Discussion

Compartment syndrome and rhabdomyolysis both result from muscle injury. Trauma and exertion are known precipitants of these conditions. Upper arm acute compartment syndrome is extremely rare, however, and its occurrence following exertion is novel. In contrast, rhabdomyolysis secondary to exertion and/or heat-related illness has been well described in the medical literature, especially in athletes and military recruits. Eccentrically based activities, performed while the muscle elongates while under tension (“negatives”), pose a particular risk for rhabdomyolysis. 11

Although the CK threshold for diagnosing rhabdomyolysis has been proposed as 5-10 times the upper limit of normal, conditioned athletes who have had CK measured post-exertion in a non-clinical setting can have very high CK values. In one study of college football players in preseason practice, the average CK was 5,125 U/L, 30 times the norm for men. The CK testing on 19-20 Aug 2010 conducted at the high school likely contributed to case finding. OPHD was unable to determine how many of the 16 rhabdomyolysis cases who were first identified through this CK testing would have sought medical care in the absence of the testing.

OPHD was unable to find any evidence that the cluster of compartment syndrome and rhabdomyolysis resulted from a primary cause that was not exertion-related.

OPHD concluded that multiple factors likely contributed to the cluster of triceps compartment syndrome and rhabdomyolysis, foremost among them an intense, short-duration, repetitive burst of resistance exercise on Sun 15 Aug 2010 that primarily involved a single muscle compartment. Additional contributing factors likely included environmental stress from heat and unrecognized dehydration. Although compartment syndrome is distinct from rhabdomyolysis, OPHD concluded that similar factors contributed to both conditions; all three cases of compartment syndrome also had rhabdomyolysis. Although uncommon, prior case reports have also found rhabdomyolysis among conditioned athletes can result from similar intense, short-duration, repetitive resistance exercises focused on a single muscle compartment.

OPHD reiterates that this report is preliminary; additional analyses are planned to better characterize this cluster of illness.

Based on this preliminary report, OPHD recommends that:

1. Oregon coaches, trainers, school administrators, health professionals, parents, and recreational athletes recognize that intense, short-duration, repetitive resistance exercise involving a single 12 muscle compartment can lead to serious health complications, particularly during exercise conditions with higher risk of heat stress and inadequate hydration.

2. Both during and outside of official sports seasons, Oregon coaches, trainers, and school administrators routinely and explicitly assess potential health and safety hazards to student-athletes, and implement appropriate countermeasures as warranted, such as activity modification, rest breaks, and hydration

ZENITH: CHILD AND YOUTH RIGHTS IN SPORTS

ZENITH I and II:

ZENITH I: The 1989 UNITED NATIONS CONVENTION ON THE RIGHTS OF THE CHILD; SPORTS FOR DEVELOPMENT AND PEACE

“The Olympic Games reached their Zenith in the 6th and 5th centuries BC. The Olympic Games program now consists of 26 sports, 30 disciplines and nearly 300 events.”[Wikipedia]

“The ancient Olympics were based on a philosophy of balance between physical / athletic and spiritual / moral development that was a cornerstone of Greek democracy.”

“The Olympic games became a link, a bond between people of a common blood. The Games were seen as a way of fostering friendship among the warring Greek city-states with the aim of forming a nation.”

“The ‘Athletic Ideal’ was the motivation behind the original Olympic Games in ancient Greece. The “Athletic Ideal” is the primary legacy of the Olympic games. It is an ideology and legacy unique in the history of the world.”

“The goal of the ‘Athletic Ideal’ was ‘a healthy mind in a healthy body’. The ancient Greeks believed that the development of the mind, spirit, and body were linked, and that a well-educated person was instructed in all areas. An athletic victory was considered a credit to both the athlete’s physical and moral virtues. Physical training was valued for its role in the development of such qualities as endurance and patience.”

“The motivation was the development of a disciplined, devout, virtuous citizen of the democracy. The philosophy was that the success of self-government (democracy) depended on the moral character of the citizenry. This was a large part of the motivation for the combined athletic / moral training.”

“This goal demanded a holistic training of mind, body, and spirit. In ancient Greece athletics were an everyday part of all areas of life religion, education, society, the arts, and politics. Physical disciplines wove themselves into the very fabric of society, leaving no area untouched. This phenomenon is completely unique in world history. Ancient Greece was the birthplace of this ideology, the Athletic Ideal.” [OLYMPIC-LEGACY.com]

All Ancient Olympic Athletes were required to take an oath that they would observe all the rules and standards for Olympic Participation. In spite of the luxurious facilities offered to athletes, all had to remain amateurs. [Origin and History of the Olympic Games From Grolier Online’s New Book of Knowledge]

Ancient Olympic Athletes were treated well. They had entourages, trainers, coaches, and masseuses. Top athletes in antiquity were equivalent to modern day NBA stars. [The Ancient Olympics, by Howard Nowes, 11/19/2004]

Ancient Olympic Athletes certainly were not victims of Athlete Abuse. They were protected and revered not maltreated. Ancient Olympic Athletes were not vulnerable. Today’s NBA Stars are well treated and not abused by Coaches and other members of the Athletic Community, because they are not vulnerable. Similar to Ancient Olympic Athletes prestige, they have the wealth and power to reject maltreatment.
Different from Ancient Olympic Athletes and Today’s NBA Stars, Child Athletes are vulnerable to Endangerment, Mistreatment and Abuse because:

• reliance and dependency on adults
• age
• Innocence
• smaller physical size
• Immaturity
• inability to defend themselves physically and psychologically
• afraid of angering the offender
• blame themselves forthe abuse
• feel guilty and ashamed
• susceptible to force, not powerful
• susceptible to the use of trickery by offenders
• have nocontrol over their own bodies
• unable to make others believe their report
• perpetrators are someone they love, trust and admire in the beginning, such as their Coach.

Every Child in the World has the Right to Play and the Right of Protection and Well-Being while playing Sports. Childhood must be a United States of America as well as Global priority in every venue, including Sports. Children’s Rights are the law; not merely luxuries.

The United Nations accepts as truth that Sport can enhance the economic, social, health and personal growth and development of all people, particularly Children. while generating widespread employment and economic activity. Sports create a world wide culture of peace and tolerance, common to all people and nations. while promoting understanding and mutual respect.

Children’s Rights are often thought of in terms of the social institutions that are created to relieve the endangerment, mistreatment, Abuse and Neglect of Children. Less attention has been paid to the institutions that develop and foster Child endangerment, mistreatment and Abuse. One example is Sport Participation when the Care-giving Coach doesn’t Properly Supervise the Athletes like other Resonable Coaches would supervise.

The Awareness of Children’s Rights in different nations around the world arise in part from “progress”. Less “progressive” nations are associated with Underprovided Rights. That contrast is not necessarily so. The development and perpetuation of Child Abuse, neglect, exploitation in modern complex, industrial societies have different mechanisms of development than non-Western, non-industrialized and third world societies. In addition, Awareness and Advocacy for Underprovided Children’s Rights have different mechanisms in those different societies. The mechanisms for the development and perpetuation of Underprovided Children’s Rights are the difference.

Both progressive and non-progressive societies have communities of poverty. Poverty is not the key to Child Abuse. Poverty does not drive Child Athlete Abuse. No social class of people are immune from Child Abuse. From the wealthiest professionals to the most impoverished, no social class dominates or is unaffected from childhood victimization. All social strata are touched by Child Abuse and Neglect, Sports included.

While institutions are different in “progressive” nations, the principles remain the same, where the maltreatment of Children is concerned. It is unlawful. State, national and international laws are similar concerning violations of Children’s Rights.

The will to enforce childhood victimization laws might vary, however. [Children’s Rights a Cross Cultural Perspective by Vandra L. Masemann University of Toronto]
As a result, the core values and unlawful behaviors are the same for most cultures and societies but the varieties of Ammodytidae and pragmatic factors are different. [RESPONSES TO CHILD ABUSE IN WORLD PERSPECTIVE,Charles L. McGehee, Central Washington University, Paper presented at the Third International Institute on Victimology, Lisbon, Nov 11-17, l98]

There are similarities and differences in abuse and violence mechanisms in general around the world. “To advance our understanding of child abuse we must pursue cross-cultural research. Awareness of child abuse, internationally, varies a great deal, often depending on the political, social, economic, and cultural milieu of the country.”

“Explanations for the variation of child abuse from one country to the next emphasize cultural differences in attitudes towards, and values placed on children, and the cultural appropriateness of using violence as a means of social control.”

[International perspectives on child abuse By Richard J. Gelles Ph.D. and Claire Pedrick Cornell M.A. Department of Sociology and Anthropology, University of Rhode Island, Kingston, RI 02881 Jamaica]

Sports have a unique standing. The endangerment, maltreatment, Abuse and Neglect of Children in Sports have a common thread worldwide. The language, characteristics and mechanisms of development of Child Athlete Abuse are very similar in all nations. Every race, class, religion, and culture participate in Sports. Amateur Sports Communities are the most comparable International societies for Child Victimization.

Thus, Children’s Rights and well-being in sports are a priority for the United Nations. The U.N. priority is appropriately so. When Properly Supervised, Sports are the ideal model for social, economic and cultural development, peace and tolerance of nations and protection of Athlete health and welfare. As for Ancient Olympic Athletes, this U.N. priority is modern-day “Athletic Ideal”.

Since the beginning of the Ancient Olympics, everytning has changed but nothing is different. Everything has changed from nation to nation, but naught is different in the International Sports Community. From that perspective, Athletes Internationally Lace-Up For the Good of All. The United Nations model for Sports Participation will diminish Child Athlete Abuse.

During the World Cup in South Africa, the sound of the 2010 World Cup horn, or vuvuzela horn, was a perfect example of tolerance, understanding and mutual respect. The annoying vuvuzela horn was the only sound heard at the 2010 World Cup. Tens of thousands of South African fans took them to games and blew the World Cup horn as loudly as they could for entire games. Even though annoyed, fans and Athletes from around the world understood their significance, tolerated and respected the South African tradition.

However, in some instances, International and U.S. Sports Participation have evolved with serious costs and consequences to Children. Shakeshaft estimates that 1%-2% school coaches are sexual abusers. The percentage of Non-school coaches is much higher. Applying that rate to the NAYS estimate of 3 million volunteer and school coaches in the United States would produce about 6,000 coaches nationwide with records of sexual abuse.

That 6,000 are only the coaches who have been convicted or are being tried. As many as 94 percent of children who are sexually molested never report the incident, according to Hofstra University education professor Charol Shakeshaft, who studied cases in New York State. No one knows how many exist, without records, who will never be caught [Violation Of Trust / When young athletes are sex-abuse victims, their coaches are often the culprits Date: 6/9/02 Author: Michael Dobie, Publication: Newsday. http://www.taasa.org/library/pdfs/TAASALibrary192.pdf]

In 2004, the John Jay report tabulated a total of 4,392 priests and deacons in the U.S. against whom allegations of sexual abuse have been made.

In a statement read out by Archbishop Silvano Maria Tomasi in September 2009, the Holy See stated “We know now that in the last 50 years somewhere between 1.5% and 5% of the Catholic clergy has been involved in sexual abuse cases”, adding that this figure was comparable with that of other groups and denominations. [Wikipedia]
What are the current serious costs and consequences to Children. Human Rights in Youth Sport, published December 2004, by Paulo David, identifies and describes these International and United States of America problems of Exploitation and Abuse of Children in Youth in Sport. They are:

• over-training
• physical, emotional and sexual abuse
• doping and medical ethics
• education
• child labor
• accountability of governments, sports federations, coaches and parents.

The final inner truth, the Athletic Ideal or Zenith of this website, CAPPAA, PREVENT ATHLETE ABUSE, is Child Athletes’ Human Rights in Sports. They are fundamental
to Sports and fundamental to all Nations of the World. The 1989 UNITED NATIONS CONVENTION ON THE RIGHTS OF THE CHILD (CRC, INCLUDES SPORTS) and the UNITED NATIONS OFFICE FOR SPORTS DEVELOPMENT AND PEACE, UNOSDP, The UN System in Action, lead the endeavor.

Why do we need an International Law for Sports Participation ? i.e. The 1989 UNITED NATIONS CONVENTION ON THE RIGHTS OF THE CHILD (that INCLUDES SPORTS). Because it spells-out, in no uncertain terms, Child Protection Laws during Children’s Sports Participation, unlike the United States Federal and State Child Protection Laws that don’t enumerate each venue of Unlawful Care-giving to Children by Supervisors.

The 1989 UNITED NATIONS CONVENTION ON THE RIGHTS OF THE CHILD (INCLUDES SPORTS) defines Child Protection in Sports with definitions of Coaches and others abnormal behaviors and actions that result in Child Athlete Abuse. [The Rule of Law Enters the Sports Arena, by Paulo David]

The 1989 UNITED NATIONS CONVENTION ON THE RIGHTS OF THE CHILD (INCLUDES SPORTS) is International Law. It is the solution to Child Athletes’ Human Rights in Sports. The 1989 UN Convention’s Treaty provides inclusive Protection of Children’s Right to Play Sports while entitling them to their Human Rights, Protection and Well-Being. Currently it is parked on President Obama’s agenda table. President Obama is considering the initiation of the ratification process.

When asked whether he would seek ratification of the CRC in the Presidential Youth Debate, Obama expressed support for that goal: “It’s important that the United States return to its position as a respected global leader and promoter of Human Rights. It’s embarrassing to find ourselves in the company of Somalia, a lawless land.

I will review this and other treaties and ensure that the United States resumes its global leadership in Human Rights.” [Child's Rights Information Network, CRIN]
Somalia and the United States are the only 2 nations in the World who have not ratified the 1989 Convention Treaty. As of November 2009, 194 countries have ratified it, including every member of the United Nations except Somalia and the United States. Somalia’s cabinet ministers have announced plans to ratify the treaty. The U.S. will most likely follow suit.

Once the treaty is ratified, the struggle for Awareness of the Laws for Children’s Rights in Sports will be recognized. The Convention Treaty, already an International Law for 194 nations, will be Supreme Law (Supremacy Clause) in the U.S. Children Athletes in the United States will finally win. Child Protection and Child Welfare in Sports will include the sting of Supreme Law once promulgated. The U.S. Federal Government’s suit against Arizona’s Immigration Law was based on the Supremacy Clause.

The Prevention of the Exploitation and Abuse of Children in Sport will be Supreme Law in the United States and truly a Hurrah Moment; a Final Moment of Glory for the Rights of Children in Sports; the Zenith.

The Rat Maze of Justice for Child Athletes that exists in the United States will not be a complex journey after the 1989 Convention Treaty is ratified. Even though United States Federal Law CAPTA 1974 (Child Abuse Prevention and Treatment Act) and State Laws (in Kentucky the Unified Juvenile Code) are the Child Protection and Criminal Codes of Conduct, they are poorly Enforced where Child Athletes are concerned. The quagmire of the U.S. Public Health Services, Social /Child Welfare Systems, Criminal Justice Departments, Education-Awareness Groups, and High School Athletic Associations and Federations will be abridged once the CRC is ratified.

To begin with, the U.S. participated in writing the text of the 1989 CRC. “In the US, the treaty power is a coordinated effort between the Executive branch and the Senate. The President may form and negotiate a treaty, but the treaty must be advised and consented to by a two-thirds vote in the Senate. Only after the Senate approves the treaty can the President ratify it. Once a treaty is ratified, it becomes binding on all the states under the Supremacy Clause.”

When we peel away the layers, the protective coverings, of ours or other Athlete’s Sports Participation, we sometimes discover the final inner truth, the heart of the issues, about that which we seek. We discover the personal health and welfare during that Sports Participation and awaken to the nature of the Sports Participation reality.

Unfortunately, Sports Participation is not always a positive experience. Sometimes the Sport has a negative impact on the Athlete. Dealing with Sports Participation’s harmful issues and healing those damaging issues are symbolized by pealing away the outer contributing truths to get to the core and seed, the place where all is understood, the final stage of the journey, final inner truth of Sports Participation’s deleterious effect. [Ref. Peeling Away The Layers]

The 1989 CONVENTION ON THE RIGHTS OF THE CHILD:

“The Convention on the Rights of the Child is the first legally binding international instrument to incorporate the full range of human rights—civil, cultural, economic, political and social rights. In 1989, world leaders decided that children needed a special convention just for them because people under 18 years old often need special care and protection that adults do not. The leaders also wanted to make sure that the world recognized that children have human rights too.”

“The Convention sets out these rights in 54 articles and two Optional Protocols. It spells out the basic human rights that children everywhere have: the right to survival; to develop to the fullest; to protection from harmful influences, abuse and exploitation; and to participate fully in family, cultural and social life.”

“The four core principles of the Convention are non-discrimination; devotion to the best interests of the child; the right to life, survival and development; and respect for the views of the child. Every right spelled out in the Convention is inherent to the human dignity and harmonious development of every child. The Convention protects children’s rights by setting standards in health care; education; and legal, civil and social services.”

“By agreeing to undertake the obligations of the Convention (by ratifying or acceding to it), national governments have committed themselves to protecting and ensuring children’s rights and they have agreed to hold themselves accountable for this commitment before the international community. States parties to the Convention are obliged to develop and undertake all actions and policies in the light of the best interests of the child.”[Wikipedia]

“The ratification of international treaties is accomplished by filing instruments of ratification as provided for in the treaty. In most democracies, the legislature authorizes the government to ratify treaties through standard legislative procedures (i.e., passing a bill).”[Wikipedia]

“In the US, the treaty power is a coordinated effort between the Executive branch and the Senate. The President may form and negotiate a treaty, but the treaty must be advised and consented to by a two-thirds vote in the Senate. Only after the Senate approves the treaty can the President ratify it. Once a treaty is ratified, it becomes binding on all the states under the Supremacy Clause.” [UNICEF: convention on the Rights of Children]

“The Supremacy Clause is a clause in the United States Constitution, Article VI, Clause 2. This clause asserts and establishes the Constitution, the federal laws made in pursuance of the Constitution, and treaties made by the United States with foreign nations as “the Supreme Law of the Land” (using modern capitalization). The text of Article VI, Clause 2, establishes these as the highest form of law in the American legal system, both in the Federal courts and in all of the State courts, mandating that all state judges shall uphold them, even if there are state laws or state constitutions that conflict with the powers of the Federal government. (Note that the word “shall” is used here and in the language of the law, which makes it a necessity, a compulsion.)” [Wikipedia]

What does sport have to do with the UN?

“The fundamental principles of sport –respect for opponents and for rules, teamwork and fair play– are consistent with the principles of the United Nations Charter.
“Sport plays a role in communities large and small. From informal recreational matches and contests, to organized sports leagues and federations, people participate: they play, coach, train, and support their favourite athletes and teams. From indigenous sports to global sporting events, sport has “convening power”. Where opportunities for recreational sport and play are absent, individuals and entire communities are often acutely aware of what they are missing.

“Sport can contribute to economic and social development, improving health and personal growth in people of all ages –particularly those of young people. Sport-related activities can generate employment and economic activity at many levels.
“Sport can also help build a culture of peace and tolerance by bringing people together on common ground, crossing national and other boundaries to promote understanding and mutual respect.”

“For many years the United Nations, its funds, programmes and related specialized agencies have acknowledged the importance of sport in society. United Nations bodies have enlisted star athletes and major sporting events in campaigns to promote immunization against childhood diseases and other public health measures, to support the fight against racism and apartheid, and for human rights. The right to play and to participate in sports have been embodied in United Nations instruments like the Convention on the Rights of the Child and The Convention on the Elimination of Discrimination against Women.

“During the past decade relations between the United Nations and civil society have grown in every respect. Relations with the sports world have reflected this trend. Since 1993 the General Assembly has adopted a succession of resolutions endorsing the Olympic Truce and development of the relationship with the International Olympic Committee (IOC).

“The IOC and National Olympic Committees (NOCs) have concluded cooperation agreements with a number of United Nations programmes and funds, including UNICEF, the Office of the High Commissioner for Refugees (UNHCR), the UN Development Programme (UNDP) and the UN Environment Programme (UNEP) to bring the benefits of sport to refugees and others affected by conflict, and to fight social exclusion and environmental degradation.

“Other sports organizations have also lent their support to UN efforts in the field. The International Volleyball Federation has supported programmes for refugees, while the International Federation of Football Association (FIFA) has established working relationships with WHO and UNICEF for campaigns against polio and for the Rights of the Child, respectively. The USA National Basketball Association has supported UN anti-drug abuse campaigns. An increasing number of non-governmental organizations at the local, national and international levels are joining forces with United Nations offices and field operations to organize promote development, health, human rights and peace through sporting events. Acknowledging the growing potential of these partnerships, in 2001 the Secretary-General appointed for the first time a Special Adviser on Sport for Development and Peace, Adolf Ogi of Switzerland.

“The UN is bringing the power of sport to help in the global fight against HIV/AIDS and to preserve the environment. Independent specialized agencies of the broader United Nations system like the International Labour Organization (ILO), the UN Educational, Scientific and Cultural Organization (UNESCO) and the World Health Organization (WHO) have also focused on the value of sport in their fields of work.

“UNESCO adopted an International Charter of Physical Education and Sport in 1978 as a result of its work with the IOC. Since 1984 WHO has engaged with the sporting world to promote a healthy lifestyle, the benefits of regular physical activity and fight tobacco use. The ILO, as part of its activities to ensure decent working conditions has worked with other UN bodies [governments and sports organizations] through a series of partnerships in which sport is a central element for promoting social and economic development. There are many more examples of the growing collaboration between sports organizations and other NGOs, UN system bodies and governments using sport to improve the lives of people and communities.

“In March 2003 a task force of experts from the United Nations and several specialized agencies submitted to Secretary-General Kofi Annan a report containing recommendations for an increased role of sport to realize United Nations efforts for development and peace.

VI. Child Protection in Sport (Agenda item 4.i)

The Group welcomed the presentation by UNICEF. The issue of Child Protection in Sport should be framed within the broader Child Rights Convention which creates obligations for its Member States. Children have a right to leisure, play and sport (art. 31), and also have the right to be protected against abuse and violence. Sport can be the cause and conduit of violence and exploitation. There should be more emphasis in sports policy on the need to protect the children and recognize their rights, and less focus on producing elite athletes. The best interests of the child should guide decisions. Examples of violence in sport include trafficking, abuse, sexual violence, child labor, and athletes forced to play when injured.

This is a very sensitive subject and challenging to study given that definitions vary from study to study, and country to country. The conceptual framework for this work strand should be to establish a protective environment. There needs to be an open debate in society, which is challenging given that child protection is so often a taboo topic. There should be a zero tolerance policy for violence against children.

The presentation went on to outline the features of a protective environment: Codes of Conduct and ethical guidelines need to be developed. Mega sports events such as the FIFA World Cup can be used to raise awareness. UNICEF will publish a report at the end of May 2010 on violence against children in sport.

The meeting agreed the importance to create protective environments. The Child Protection in Sport priority is clear and there is only one Policy Recommendation: ‘Develop policies with specific provisions and implementation plans to prevent the exploitation and abuse of children and youth in sport contexts’.

The question of the definition of ‘child’ in sport was raised and it clarified that a child is under the age of 18. The same applies in sport unless national legislation sets the age younger. [Sport for Development and Peace International Working Group 1st Plenary Session, Geneva, Switzerland, 5 May 2010 Minutes Secretary: Mr. Poul Hansen, Head of UN Office on Sport for Development and Peace, SDP IWG Secretariat. Presiding Officer: Ms. Debbie Lye, Head of International Development,
International Inspiration Programme Director, UK Sport.]

UNITED NATIONS / UNOSDP

“The United Nations Office on Sport for Development and Peace (UNOSDP), based in Geneva and supported by a Liaison Office in New York , assists the Special Adviser to the United Nations Secretary-General on Sport for Development and Peace in his worldwide activities as an advocate, facilitator and representative of sports’ social purposes.

“The Office provides the entry point to the United Nations system with regard to Sport for Development and Peace, and works at bringing the worlds of sport and development together.

“Practitioners, policy-makers, researchers, journalists, communications specialists, entrepreneurs, athletes, volunteers and other stakeholders throughout the world are urged – and assisted in doing so – to meet the challenges and work outlined in the three-year Action Plan contained in the 2006 report of the Secretary-General “Sport for development and peace: the way forward” (A/61/373). [The United Nations Office on Sport for Development and Peace (UNOSDP)]

“Child Protection in Sport

“While recognising that every youth and child has a right to sport and play, the human rights of participants must be respected and protected. The most common forms of abuse in sport are physical, sexual, psychological and neglect; abuse that can have devastating consequences for the health and development of children. The SDP IWG Report, “Harnessing the Power of Sport for Development and Peace:
“Recommendations to Governments”, made the following policy and programmatic recommendations which Member States, with SDP IWG support, are encouraged to implement:

“POLICY RECOMMENDATIONS:

• Develop policies with specific provisions and implementation plans to prevent the exploitation and abuse of children and youth in sport contexts.”

Unfortunately, Child Athletes in the United States will need the ratification of the 1989 UNITED NATIONS CONVENTION TREATY ON THE RIGHTS OF THE CHILD that INCLUDES SPORTS, an International Law, to intervene for their over-training, physical, emotional and sexual abuse, doping and medical ethics, education, child labour and accountability of Federal and State Governments, sports federations and associations, coaches and parents and the Entire Athletic Community, even though Federal and State Child Protection Laws are already included in the United States Criminal Code of Conduct.
____________________________________________________________________

ATHLETE ABUSE EXAMPLES
“Child abuse and neglect are defined by Federal and State laws. The Federal Child Abuse Prevention and Treatment Act (CAPTA 1974) provides minimum standards that States must incorporate in their statutory definitions of child abuse and neglect. The CAPTA definition of “child abuse and neglect,” at a minimum, refers to:
“Any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act or failure to act which presents an imminent risk of serious harm”1

Types of Abuse

Physical Abuse

“Physical abuse is generally defined as “any nonaccidental physical injury to the child” and can include striking, kicking, burning, or biting the child, or any action that results in a physical impairment of the child.” Also includes acts or circumstances that threaten the child with harm or create a substantial risk of harm to the child’s health or welfare.

Neglect

“Neglect is frequently defined as the failure of a parent or other person with responsibility for the child to provide needed food, clothing, shelter, medical care, or SUPERVISION such that the child’s health, safety, and well-being are threatened with harm.”

Sexual Abuse/Exploitation

All States include sexual abuse in their definitions of child abuse. Sexual exploitation is an element of the definition of sexual abuse in most jurisdictions. Sexual exploitation includes allowing the child to engage in prostitution or in the production of child pornography.

Emotional Abuse

“Typical language used in these definitions is “injury to the psychological capacity or emotional stability of the child as evidenced by an observable or substantial change in behavior, emotional response, or cognition,” or as evidenced by “anxiety, depression, withdrawal, or aggressive behavior.” [Definitions of Child Abuse and Neglect: Summary of State Laws, Child Welfare Information Gateway, 2009]

____________________________________________________________________
Human Rights in Youth Sport by Paulo David ISBN:9780415305587
Author:David, Paulo Publisher:Routledge

Publisher Comments: “The human rights of the child have been inscribed in the UN’s 1989 Convention on the Rights of the Child, and ratified by 191 countries. Paulo David’s work makes it clear, however, that too often competitive sports has yet to recognize the value of respect for international child rights norms. “Human Rights in Youth Sport” offers critical analysis of some very real problems within youth sport and argues that the future development of sport depends on the creation of a child-centered sport system. Areas of particular concern include issues of over training, physical, emotional, and sexual abuse, doping and medical ethics, education, and child labor. The text also examines the specific responsibilities and accountabilities of parents, coaches, and managers and should be essential reading for anybody with an interest in the ethics of sport, youth sport, coaching, and sports development.”
_________________________________________________________________

“The Campaign for U.S. Ratification of the Convention on the Rights of the Child (CRC)
is a volunteer-driven network of academics, attorneys, child and human rights advocates, educators, members of religious and faith-based communities, physicians, representatives from non-governmental organizations, students, and other concerned citizens who seek to bring about U.S. ratification and implementation of the CRC.
Background

During the 2002 UN Special Session on Children, members of the U.S. delegation dismissed the CRC and its principles. Their criticism of the CRC underscored a lack of unified action over the years by U.S. proponents of the CRC to address incomplete or misleading information about the Convention.

Through the leadership of the Child Welfare League of America (CWLA), a core group of child advocates convened the first meeting of the Campaign for U.S. Ratification of the CRC in August 2002. Participants focused on efforts needed to build a national coalition.

In 2003, representatives from more than 50 U.S. non-governmental organizations met in Washington, DC for a two day strategy session entitled “Moving the CRC Forward in the United States”. Out of this effort, the Campaign for U.S. Ratification of the CRC was formalized. From its origins, the Campaign has grown to encompass membership from 200 organizations and academic institutions.

Children occupy a unique status in our society. While they are entitled to the basic rights prescribed in their nations’ Constitutions, their status, as minors, renders them vulnerable and in need of safeguards to ensure their protection.

In recognition of children’s special status, the United Nations commenced efforts in 1979 to develop an inclusive, legally-binding human rights treaty for all the world’s children. Ten years later, the Convention on the Rights of the Child (CRC) was adopted by the United Nations General Assembly in 1989 and instituted as international law in 1990.

Despite that the U.S. was an active and prominent participant in the decade-long drafting process, we, along with Somalia, remain the only two nations a party to the UN who have not ratified this celebrated document. The 194 countries that have ratified the Convention has used it as a guide to develop and implement policies and programs that best address and fulfill children’s needs.

Our children are our future decision-makers and leaders. They will set public policy and implement laws. In essence, they will shape the future of not only American society and culture, but that of the world. Thus, we need to raise resilient children who will make good citizens, who care about others, who share our values, and who will make excellent parents. In order for children to thrive, childhood needs to be made a national as well as global priority.

Children are seldom considered as a factor in decision-making. It is passed the time that we think about how our decisions affect the lives of each and every child. After all, we are going to have to live with the consequences of our actions.”

__________________________________________________________________

Who enforces International Human Rights, and how?

The International Criminal Court was set up in 2002 to try individuals accused of genocide, war crimes and crimes against humanity.

On 7 October 2004, the General Assembly adopted Resolution number AG-2004-PRES-17 which recommended that, within the limits of national and international law, ICPO-Interpol member countries should cooperate with each other and with international organizations, international criminal tribunals, and non-governmental organizations as appropriate in a joint effort to prevent genocide, war crimes, and crimes against Humanity, and to investigate and prosecute those suspected of committing these crimes; asked the General Secretariat to assist member countries in the investigation and prosecution of these crimes; and asked the Secretary General to bring the present resolution to the attention of the appropriate United Nations authorities and other international organizations.

The General Assembly Delegates also authorized an accord to be signed with the Office of the Prosecutor of the International Criminal Court to improve co-operation between the two organizations in assisting the fight against transnational crime and upholding justice. The agreement will also allow the International Criminal Court access to Interpol’s communications network and databases.

The Investigation and Prosecution of Genocide, War Crimes, and Crimes against Humanity:

The General Secretariat is expanding its role in providing international co-ordination and support for law enforcement agencies in member countries and international organizations responsible for the investigation and prosecution of genocide, war crimes, and crimes against Humanity.

Interpol has been supporting member countries and the ad hoc International Criminal Tribunals in the location and apprehension of criminals wanted for genocide, war crimes, and crimes against Humanity since 1994, primarily through the publication of Red Notices and the provision of other investigative assistance. However, many countries have recently expanded their activities in this field, and have established specialized units dedicated to the investigation and prosecution of these offences regardless of where they have occurred.

About 6,000 school and volunteer coaches in the U.S. have records of sexual abuse. 1%-2% school coaches are sexual abusers. 4,392 (2004) priests and deacons in the U.S. against whom allegations of sexual abuse have been made. Between 1.5% and 5% of the Catholic clergy has been involved in sexual abuse cases

April 8, 2010 (C-FAM) - In London last Friday, a high ranking United Nations (UN) jurist called on the British government to detain Pope Benedict XVI during his upcoming visit to Britain, and send him to trial in the International Criminal Court (ICC) for for sexual abuse in the Catholic Church.

Who do we detain and turn over to the International Criminal Court for Crimes against Humanity (Child Athletes) because thousands of Coaches have committed Child Athlete Sexual Abuse?

The United Nations and the International Criminal Court have relationship governed by the “Relationship Agreement”.

NFHS Member Associations: The active members of the National Federation of State High School Associations are the 50 state high school athletic/activity associations, plus the District of Columbia. There also are affiliate athletic/activity members, including associations in the U.S. territories, Canada and other neighboring countries.
About US: Since 1920, The National Federation of State High School Associations has led the development of education -based interscholastic sports and activities that help students succeed in their lives. We set directions for the future by building awareness and support, improving the participation experience, establishing consistent standards and rules for competition, and helping those who oversee high school sports and activities.

The NFHS, from its offices in Indianapolis, Indiana, serves its 50 member state high school athletic/activity associations, plus the District of Columbia. The NFHS publishes playing rules in 16 sports for boys and girls competition and administers fine arts programs in speech, theater, debate and music. It provides a variety of program initiatives that reach the 18,500 high schools and over 11 million students involved in athletic and activity programs.

The Coaches Code of Ethics: http://www.nfhs.org/content.aspx?id=2825
________________________________________________________________

The International Criminal Court was set up in 2002 to try individuals accused of genocide, war crimes and crimes against humanity.

April 8, 2010 (C-FAM) - In London last Friday, a high ranking United Nations (UN) jurist called on the British government to detain Pope Benedict XVI during his upcoming visit to Britain, and send him to trial in the International Criminal Court (ICC) for “crimes against humanity.” (for sexual abuse in the Catholic Church) The Intenational Crimnal Court has the power to Enforce International Law i.e. 1989 UNITED NATIONS CONVENTION ON THE RIGHTS OF THE CHILD.

In 2004, the John Jay report tabulated a total of 4,392 priests and deacons in the U.S. against whom allegations of sexual abuse have been made.

In a statement read out by Archbishop Silvano Maria Tomasi in September 2009, the Holy See stated “We know now that in the last 50 years somewhere between 1.5% and 5% of the Catholic clergy has been involved in sexual abuse cases”, adding that this figure was comparable with that of other groups and denominations. [Wikipedia]

Charol Shakeshaft estimates that 1%-2% school coaches are sexual abusers. The percentage of Non-school coaches is much higher. Applying that rate to the NAYS estimate of 3 million volunteer and school coaches in the United States would produce about 6,000 coaches nationwide with records of sexual abuse.

That 6,000 are only the coaches who have been convicted or are being tried. As many as 94 percent of children who are sexually molested never report the incident, according to Hofstra University education professor Charol Shakeshaft, who studied cases in New York State. No one knows how many exist, without records, who will never be caught [Violation Of Trust / When young athletes are sex-abuse victims, their coaches are often the culprits Date: 6/9/02 Author: Michael Dobie, Publication: Newsday. http://www.taasa.org/library/pdfs/TAASALibrary192.pdf]

“Legislation exists to protect human rights, but it is much more difficult to ensure that states respect the treaties they have signed. Two covenants, on civil and political rights and on economic, social and cultural rights, were adopted in 1966. Other treaties, on children’s rights, women’s rights, racial discrimination and torture, have followed. Nearly every government has signed at least one of these international treaties. The International Criminal Court was set up in 2002 to try individuals accused of genocide, war crimes and crimes against humanity.” [Lara Iglitzen, Executive Director, Henry M. Jackson Foundation]

“To enforce the protections found in human rights covenants and treaties, people push governments to bring their actions into line with international standards by using in-country justice systems or human rights bodies, regional human rights commissions or courts, the United Nations human rights system, and by applying political pressure from within or outside the country.” [Mary Ann Stein, President, The Moriah Fund]

“Non-state actors act autonomously from recognized governments. They may include armed paramilitary groups, insurgents, guerrillas, liberation movements, NGO [Non-Governmental Organization (NGO) is a legally constituted organization created by natural or legal persons that operates independently from any government], corporations, educational institutions, private donors, religious organizations, the scientific community, private individuals, the media, etc. Their few shared characteristics result from their distinctly unofficial nature (compared with state actors), their greater flexibility and, often, their unaccountability under national and international laws. Non-state actors vary greatly in ideology, objectives, strategies, form and level of organization, support-base, legitimacy and degree of international recognition. There is growing recognition of the need to ensure that non-state actors also comply with international human rights laws.”[Joe Wilson, Program Officer, Public Welfare Foundation]

“A non-governmental organization (NGO) is an organization which is not a part of a government…….NGOs exist for a variety of different purposes, usually to further the political and/or social goals of their members. Some example goals include improving the state of the natural environment, encouraging the observance of human rights, improving the welfare of the disadvantaged, or representing a corporate agenda. However, there are a huge number of such organizations and their goals cover a broad range of political and philosophical positions. This can also easily be applied to private/semi-private schools and athletic organizations.” [WordIQ]

Specifiers’ Library NGO List:

NFHS - National Federation of State High School Associations, www.nfhs.org
(All States High School Athletic Associations are members)
NCAA - National Collegiate Athletic Association
___________________________________________________________________

ZENITH II: UNOSDP

UNOSDP (The United Nations Office on Sport for Education, Health, Development and Peace)

“Sport is a language that everyone of us can speak.” Bon Ki-moon, United Nations Secretary-General

With the International Criminal Court, a new age of accountability, By Ban Ki-moon
Saturday, May 29, 2010

http://www.washingtonpost.com/wpdyn/content/article/2010/05/28/AR2010052803696.html

“Sport as a means to promote education, health, development and peace”
“Building a peaceful and better world through sport and the Olympic ideal”
UN Inter-Agency Task Force on Sport for Development and Peace defined Sport:
“all forms of physical activity that contribute to physical fitness, mental well-being and social interaction, such as play, recreation, organized or competitive sport, and indigenous sports and games.” This definition has been accepted by many proponents of UNOSDP and is the working definition of sport for the purposes of this report.

“Yearly since 2003, the UN General Assembly has adopted a resolution on the theme of ‘Sport as a means to promote Education, Health, Development and Peace’ (resolution 58/5) of 3 November 2003, 59/10 of 27 October 2004, 60/8 of 3 November 2005, 60/9 of 3 November 2005, 61/10 of 3 November 2006, and 62/271 of 23 July 2008). Resolution 58/5 proclaimed 2005 as the International Year of Sport and Physical Education.”

“Since the inception of the mandate of the Special Adviser to the UN Secretary-General on Sport for Development and Peace in 2001, Member States of the United Nations (including the United States of America) have increasingly expressed their support and commitment to sport for development and peace:”
1. Education
2. Health
3. Development
4. Peace

“The United Nations Office on Sport for Development and Peace (UNOSDP), based in Geneva and supported by a Liaison Office in New York , assists the Special Adviser to the United Nations Secretary-General on Sport for Development and Peace in his worldwide activities as an advocate, facilitator and representative of sports’ social purposes.

The Office provides the entry point to the United Nations system with regard to Sport for Development and Peace, and works at bringing the worlds of sport and development together.

Practitioners, policy-makers, researchers, journalists, communications specialists, entrepreneurs, athletes, volunteers and other stakeholders throughout the world are urged – and assisted in doing so – to meet the challenges and work outlined in the three-year Action Plan contained in the 2006 report of the Secretary-General “Sport for development and peace: the way forward” (A/61/373):

• (a) advancing a common global framework for Sport for Development and Peace;
• (b) promoting and supporting the systematic integration and mainstreaming of Sport for Development and Peace as an instrument in development plans and policies;
• (c) enhancing coordination to promote innovative funding mechanisms and multi-stakeholder arrangements on all levels, including the engagement of sport organizations, civil society, athletes and the private sector;
• (d) developing and promoting common evaluation and monitoring tools, indicators and benchmarks based on commonly agreed standards aiming towards mainstreaming sport for development and peace.

Recognizing the importance of sustaining momentum around the development potential of sport, UNOSDP performs the following duties:

ADVOCACY AND GUIDANCE

Through conferences, reports, official resolutions, media outreach, public relations and networking, UNOSDP assists the Special Adviser in raising awareness about the use of physical activity, sport and play as powerful tools in the advancement of development and peace objectives, including the Millennium Development Goals (MDGs) with the aim of encouraging the mainstreaming and replication of initiatives that truly make a difference.

UNOSDP also provides guidance and assistance to those who currently engage or would like to engage in harnessing the potential of sport as a force for good.
FACILITATION AND COORDINATION

Emphasising dialogue, knowledge-sharing and partnerships, UNOSDP serves as a facilitator, encouraging cross-cutting and interdisciplinary exchanges between all stakeholders interested in using sport as a tool for education, health, development and peace.

In the lead-up to and during major global sports events, UNOSDP works on fostering UN-wide coordination and representation. In relation to the Olympic and Paralympic Games in Beijing in 2008 , UNOSDP was instrumental in collecting and disseminating information on the projects undertaken by the UN system at headquarters level as well as in China. For both events, the Special Adviser was designated to represent the UN Secretary-General and to head the UN delegation.”

UN MEMBER STATES

“The UN is made up of 192 Member States (including the United States of America) who play a crucial role moving forward, contributing to and supporting the Sport for Development and Peace movement globally. UN Member States are Members of inter-governmental bodies that address the issue of Sport for Development and Peace such as the Sport for Development and Peace International Working Group (SDP IWG) and UNESCO’s Intergovernmental Committee for Physical Education and Sport (CIGEPS).

To fully harness the potential of Sport for Development and Peace, UN Member States must ensure appropriate national government policies, investment and capacity are provided to support programmes, and where appropriate, to scale-up these programmes on a nationwide basis. As sport is a cross-cutting issue, a broad range of government actors are potentially involved including sport, youth, health, education, finance, persons with disabilities, gender, foreign affairs, economic development and labour Ministries and departments.

National governments can play a key role in convening international, national and sub-national stakeholders to encourage knowledge exchange, networking, collaboration, partnerships and coordinated participation in national Sport for Development and Peace policy and programme development and implementation.”

____________________________________________________________________

Main Reference: Human Rights in Youth Sport A Critical Review of Children’s Rights in Competitive Sport, Author: Paulo David, ISBN: 978-0-415-30559-4 (paperback) 978 0-415-30558-7 (hardback) 978-0-203-51103-9 (electronic), No. of pages: 338 Series: Ethics and Sport, Subjects: Ethics and Philosophy of Sport; Sports Coaching; Youth Sport;, Publisher: Routledge, UK, PAULO DAVID, Officer-in-Charge of the Human Rights Treaty Division of the Office of the High Commissioner for Human Rights.
_______________________________________________________________

LEARNING ABOUT CONSUSSION DANGERS

Concussion Signs and Symptoms

When an athlete gets a direct or indirect hit to the head that causes physical signs, loss of consciousness (LOC) and post-traumatic amnesia, or physical symptoms i.e. headache, the most frequently reported symptom), mental, feeling like in a fog, and/or emotional i.e. uncontrolled laughter, sadness or crying.

The Post-Concussion Symptom Scale (PCSS) comprised of:

• Signs - noticed by coaches, parents and teammates
• Symptoms - feelings or problems expressed by the athlete

Sgns and Symptoms of concussion categories:

1. Physical - headache, nausea, vomiting, dizziness, visual problems, sensitivity to light/noise, balance problems);
2. Conciousnes, Cognitive - feeling mentally “foggy,” feeling slowed down, difficulty concentrating and remembering (e.g. amnesia)
3. Emotional (irritability, sadness, nervousness, more emotional); and
4. Sleep (drowsiness, difficulty falling asleep, sleeping less than usual, sleeping more than usual). 1.
5. A detailed concussion history is also an important part of the evaluation, both in the injured athlete and when taking a pre-participation physical evaluation or examination.

NO SAME DAY RETURN TO PLAY

“The 3rd International Consensus Statement on Concussion in Sport (May 2009) “strongly endorsed the view that children should not be returned to practice or play until clinically completely symptom-free, which may require a longer time frame than for adults.”

“ It is not appropriate for a child or adolescent athlete with concussion to return to play on the same day as the injury regardless of the level of athletic performance.”

Studies show that child and youth athletes might manifest neuropsychological signs and symptoms that may not be evident during an initial sideline evaluation and they are more likely to have delayed onset of symptoms than adult athletes.

“As a result, the Zurich Consensus Statement emphasizes the importance of treating athletes under 18-years-old more conservatively (such as by extending the amount of time of asymptomatic rest and/or the length of time for completing the symptom-limited, exercise program recommended before return to play), even if the resources (e.g. the presence of team physicians experienced in concussion management, access to neuropsychologists, consultants, neuroimaging etc.) are the same as for an older, professional athlete.”

The Zurich Consensus Statement recommendations are if a concussion is suspected the athlete should not return to play the same day and should only return to play after a written, signed clearance from a “concussion specialist”.

Concussion Signs and Symptoms, MOMS TEAM Concussion Safety Center,
Concussion Signs and Symptoms

Read more: http://www.momsteam.com/health-safety/concussion-safety/concussion-signs-and-symptoms-PCSS#ixzz1UR93IIXC
Self-reporting of the number and severity of symptoms under the Post-Concussion Symptom Scale is critical in treating concussion By Lindsay Barton Reviewed by MeehanWPMD

References:
Meehan W, d’Hemecourt P, Comstock D. High School Concussions in the 2008-2009 Academic Year: Mechanism, Symptoms, and Management. Am. J. Sports. Med. 2010; 38(12): 2405-2409 (accessed December 2, 2010 at http://ajs.sagepub.com/content/38/12/2405.abstract?etoc).
Blinman TA, Houseknecht E, Snyder C, Wiebe DJ, Nance ML. Postconcussive symptoms in hospitalized pediatric patients after
mild traumatic brain injury. J Pediatr Surg. 2009;44(6):1223-1228.
Halstead, M, Walter, K. Clinical Report - Sport-Related Concussion in Children and Adolescents. Pediatrics 2010;126(3): 597-615 at notes 40-42.
Sport Concussion Assessment Tool 2 (SCAT2), Br. J. Sports Med. 2009; 43: i85-i88; Guskiewicz, KM, Bruce SL, Cantu RC et al. National Athletic Trainers’ Association position statement: management of sport-related concussion. J. Athl. Train. 2004; 29(3): 280-287.
Gioia, GA. Schneider JC. Vaughan CG. Isquith PK. Which symptom assessments and approaches are uniquely appropriate for pediatric concussion? Br. J. Sports Med. 2009; 43 (suppl1): i13-i22.
Concussion Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008, P. McCrory et. al, Br. J. Sports Med. 2009; 43; i76-i84.
Frommer L, Gurka K, Cross K, Ingersoll C, Comstock R.D., Saliba S. Sex Differences in Concussion Symptoms of High School Athletes. Journal Ath. Train. 2011; 46(1):000-000.
Lau BC, Collins MW, Lovell MR. Sensitivity and Specificity of Subacute Computerized Neurocognitive Testing and Symptom Evaluation in Predicting Outcomes After Sports-Related Concussion. Am. J. Sports Med. 2011; 20(10), published on February 7, 2011 as dol:10.1177/0363546510392016 (accessed February 16, 2011).
Meehan WP, Kids, Sports, and Concussion (Praeger 2011).
Notes
1. Pardini D, Stump JE, Lovell MR, Collins MW, Moritz K, Fu FH. The post-concussion symptom scale (PCSS): a factor analysis. Br. J Sports Med. 2004;38:661-662.
2. Frommer L, Gurka K, Cross K, Ingersoll C, Comstock R.D., Saliba S. Sex Differences in Concussion Symptoms of High School Athletes. Journal Ath. Train. 2011; 46(1):000-000.
3. Meehan W, d’Hemecourt P, Comstock D, High School Concussions in the 2008-2009 Academic Year: Mechanism, Symptoms, and Management. Am. J. Sports. Med. 2010; 38(12): 2405-2409 (accessed December 2, 2010 at http://ajs.sagepub.com/content/38/12/2405.abstract?etoc).
4. Symptom descriptions courtesy of Robin Karpf,M.D., Medical Director, Al Rashid Health and Wellness Center, The Lawrenceville School, Lawrenceville, New Jersey.
5. Iverson GL, Lovell MR, Collins MW. Validity of ImPACT for measuring processing speed following sports-related concussion. J Clin Exp Neuropsychol. 2005; 27(6):683-689.
Revised and updated July 25, 2011

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CONCUSSION: BASELINE AND POST-INJURY TESTING

Dr. Robert Cantu says Baseline and Post-Injury Neuropsychological Testing IS A Valuable Tool in Concussion Management [MOMS TEAM The Trusted Source for Sports Parents]

Recent studies demonstrated the value of neuropsychological testing in evaluating the cognitive effects of and recovery from sport-related concussions. It has become increasingly popular. According to the 2004 Prague consensus statement, testing is a “cornerstone” of concussion evaluation.

Baseline pre-injury and post-injury testing is now frequently utilized in professional, college and increasingly in high school. The cost is sometimes a limiting factor.

“Standard Pen-and-paper neuropsychological tests have proven useful for identifying cognitive deficits resulting from concussions, and have been available to sports medicine clinicians for several years. These tests are designed to assess various domains of cognitive functioning such as short-term memory, working memory, attention, concentration, visual spatial capacity, information processing speed, and reaction time. The tests assist clinicians in quantifying the severity of the injury and eliminating some of the guesswork. The key to a successful testing program is having results from pre-season baseline testing for comparison to post-injury results.”

“Because most states require advance training and licensing to purchase and use neuropsychological tests, and they are copyright protected, the NATA’s 2004 Position Statement recommends that a licensed psychologist, preferably board-certified in clinical neuropsychology or with clinical experience in evaluating sport-related concussions, oversee and supervise the testing. These requirements are, unfortunately, likely to restrict how widely testing can be implemented at the high school level and in rural areas where access to neuropsychologists for consultation is likely to be limited.”

Computerized Neuropsychological Tests programs have been developed and are currently being sports tested and have advantages over traditional pen and paper neuropsychological tests. Widespread use of such tests faces many of the same challenges as with use of pen-and-paper tests, including:

There is a debate about test timing. There are two main approaches. After symptoms clear: This is the view taken in the Summary and Agreement Statement of the 2nd International Conference on Concussion in Sport held in Prague in 2004. Testing at fixed time intervals: Some clinicians incorporate neuropsychological testing at fixed time points (e.g. postinjury day 1, day 7, etc.) until the test results return to normal, pre-injury (e.g. baseline) levels and the players is asymptomatic..

“Regardless of which approach is taken, return to play decisions should be based on all clinical information, including the player’s medical history i.e. history of prior concussions, severity, whether subsequent concussions occur with less impact force; recovery time”.

____________________________________________________________________
CONCUSSION
The Kentucky Traumatic Brain Injury Prevalence Study January, 2004 showed that sports and recreational activities were the second leading cause of Traumatic Brain Injuries in Kentucky. Sports and recreational represents 17.1% of TBI. Automobile accidents were first at 34%. These two were by a considerable margin the leader categories. 1.

American football athletes and coaches often suffer with mental illness and depression from concussions. Multiple head injuries have been shown to result in severe mental illness to football players later in their life. A traumatic brain injury is characterized by loss of consciousness, confusion, amnesia for the events, and other neurological signs. Concussion often results later with loss of mental functioning, memory, migraine, seizures, dizziness, and depression.

Charlie Pell, a Bear Bryant disciple, and an assistant to Charlie Bradshaw at UK from 1965-1969 suffered with severe depression. Pell made a public service documentary about his depression for the state of Alabama. His documentary was a very noble achievement and an excellent source of public information.

Bear Bryant said he cried often when head coach at Kentucky. He would often stop and vomit on the way to football practice and games. “I’ll tell you I’ve cried, literally cried like a baby” over some minimal matters.

Bryant was a textbook of depression. He felt hopelessness and insecurity. Bryant manifest the depressive symptoms of inappropriate crying, empty feelings, loss of confidence and loss of temper. He was irritable, felt miserable, had difficulty sleeping and awakened too early. 5.

An investigation has been conducted concerning the association between prior head injury and the likelihood of being diagnosed with clinical depression among retired professional football players. Depression is the most cited psychological disturbance after traumatic brain injury, with prevalence rates from 6% in cases of mild traumatic brain injury to 77% in more severe TBI within the first year after injury. Retired players reporting three or more previous concussions (24.4%) were three times more likely to be diagnosed with depression; those with a history of one or two previous concussions (36.3%) were 1.5 times more likely to be diagnosed with depression. 2.

“In 2001 Kevin Guskiewicz, research director of the Center for the Study of Retired Athletes at the University of North Carolina at Chapel Hill was surprised by the depression statistics. Athletes with no concussions had a lifetime diagnosis rate of 6.6 percent. That is about the same as the general male population. Once they suffered three or more traumas, however, the rate skyrocketed to 20.2 percent. The depressions, can interact with other health problems to destroy the former athletes’ lives. The depressions have a snowball effect. The football player is retired from football, overweight, has musculoskeletal problems like sore knees, ankles, hips, not exercising. and life begins to go downhill.” 4.

Concussions can trigger a chemical chain reaction in brain neurons that that can cause athlete disorientation, unconsciousness, or death. TBI can also impair learning over a period of years. Barret Robbins, Oakland Raiders Pro Bowl center, suffered from severe depression. “The demons running loose inside Barret Robbins’ head put the football player in a San Diego hospital on Super Bowl Sunday”.

The physical power of his 6-foot-3, 320-pound body was no match for the illness. Athletes can be devastated by emotional and physical changes that come with depression. Worse is the athletes’ unwillingness to deal with their condition. The tough-man football environment makes them ashamed of their supposed “weakness,” Physical side effects from medication and the depression are the most difficult opponents they will ever confront.

”As athletes, we are taught to be tough,” said former NHL all-star Pat LaFontaine, who has battled depression. “You get up and shake it off. But you can’t do that with depression. For me, the harder I tried, the worse it got.” Spiraling into shadows so dark she thought she’d never get out, former U.S. Olympic diver Wendy Williams once collapsed in front of her refrigerator, overwhelmed by something as simple as deciding what to eat. She quit getting into her car for fear she would drive off a cliff to escape her misery. 3.

Harry Carson, middle linebacker with the New York Giants was a renowned defensive football player, intelligent, athletic and forceful, selected for the Pro Bowl. He was known for aggression. After a collision a dazed, Carson got up and walked back into the Giants’ huddle. As he stood holding his teammates’ hands, everything went black. He didn’t faint or stop playing. He was unable to figure out his coach’s signals from the sidelines. He couldn’t call the next play, as the middle linebacker is expected.
Blackouts like these were becoming familiar sensations for Carson. Over 13 seasons, he estimates he received between 15 and 18 concussions. Toward the end of his career Carson began to exhibit the cumulative effects of all these hits. He developed post concussion syndrome.

Carson developed headaches and muscle twitches. He grew sensitive to bright lights and loud noises, making it difficult for him to sit in a busy restaurant or do a television interview. He’d lose track of time. Athletes like Carson were not studied by scientists until recently. Because of the numerous football fatalities each year in the 1960s, particularly at the high school level, researchers were much more concerned with on-field catastrophes.

“When someone dies, that catches everyone’s attention,” says neurosurgeon Robert Cantu, medical director of the National Center for Catastrophic Sports Injury Research. “It’s not surprising that fatalities in football have been tracked since 1931.”

“Thanks to better protective equipment and safer coaching techniques, football deaths have now dropped to single digits each year. The decline has allowed scientists to focus on more subtle traumas, and concussions are chief among them. Neurosurgeons have shown that even a minor ding can trigger a neurological cascade that can eventually cause cognitive dysfunction and mental illness. Among retired football players who have sustained three or more concussions, 20 percent have been diagnosed with clinical depression—more than three times the rate of players who never got a concussion.”

Half of those players are taking antidepressant medications. Most report that the condition impedes their normal daily activities, such as shopping for groceries and going to work. At the UCLA Brain Injury Research Center, neuropsychologist David Hovda has studied the cascade of these injuries. An injured athlete may be oblivious to the neurochemical cascade inside his brain. “You can see a broken arm,” says Carson. “You can see a torn ligament in the knee. But with a concussion, you don’t see it.” The effects show up in statistical research.

Many other sports other than American football have frequent concussions. Soccer, hockey and baseball are examples. Matser and Lezak compared the results of swimmers and runners and found the soccer players were three to four times more likely to show deficits in memory and planning skills. The more concussions players suffered, the lower their scores on three of the 16 tests. Lezak is unsurprised. “I know what happens when you bat on the brain,” she says. “Given what we know about boxing, it would have been surprising if we hadn’t found anything. In soccer, people are punishing themselves in much the same way boxers do.”

The athletic community has developed a heightened awareness concerning traumatic brain injury and concussion. Scientists are researching concussion pathology.

Manufacturers are developing better protective helmets. Taking the head out of football during blocking and tackling is an extremely important technique that should be instructed and enforced.

References:

1. University of Kentucky Center on Drug and Alcohol Research
KENTUCKY TRAUMATIC BRAIN INJURY PREVALENCE STUDY
January 2004 Prepared For The Kentucky Traumatic Brain Injury Trust Fund Board and The Kentucky Department of Mental Health and Mental Retardation, Brain Injury Services Unit, Colleen A. Ryall, Ed.D., Director Report Prepared by: Robert Walker, M.S.W., L.C.S.W., Assistant Professor TK Logan, Ph.D., Associate Professor Carl Leukefeld, D.S.W., Professor and Director Erin Stevenson, M.S.W., Research CoordinatorCDAR TECHNICAL REPORT NO. 2004-01
2. Recurrent Concussion and Risk of Depression in Retired Professional Football Players MedScape Posted 06/19/2007 Kevin M. Guskiewicz; Stephen W. Marshall; Julian Bailes; Michael McCrea; Herndon P. Harding Jr; Amy Matthews; Johna Register Mihalik; Robert C. Cantu
3. Fearsome opponent By Patrick Saunders Denver Post Sports Writer Monday, March 10, 2003 - Bipolar disorder.
4. Discover Science, technology, the future Lights Out Can contact sports lower your intelligence? by Barry Yeoman December 3, 2004
5. SIVAULT August 15, 1966, “I’ll Tell You About Football” by Paul Bryant and John Underwood

SEXUAL ATHLETE ABUSE

SEXUAL ATHLETE ABUSE - COACHES WHO PREY ON ATHLETES
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In U.S. schools, educators who sexually offend Child and Youth Athletes range in age from “21 to 75 years old, with an average age of 28″ with teachers, coaches, substitute teachers, bus drivers and teacher’s aides (in that order) totaling 69% of the offenders. [111] Shakeshaft, C, “Educator Sexual Misconduct: A Synthesis of the Literature”, U.S. Department of Education, 2004, p24-25. Perhaps the largest contributor to the issue of coaches and sexual abuse is lack of awareness and education. Ref: The Dark Side of Youth Sports: COACHES SEXUALLY ABUSING CHILDREN - the need for a code of conduct USA Today (Society for the Advancement of Education), Jan, 2000 by Leonard D. Zaichkowsky Leonard D. Zaichkowsky is coordinator of the Sport and Exercise Psychology Program, Boston (Mass.) University, a member of the Board of Advisors of the National Youth Sports Safety Foundation, and a consulting psychologist for the National Basketball Association’s Boston Celtics.
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BY CHRISTINE WILLMSEN, THE SEATTLE TIMES

The Times found in the growing world of girls’ sports, 159 coaches have been reprimanded or fired for sexual misconduct in the past decade, and that 98 of them continued to coach or teach as the schools, the state and even some parents looked the other way.

We discovered school officials often failed to investigate coaches when faced with complaints and sometimes ignored a law requiring them to report suspected abuse to police and the state education office.

But the story wasn’t just about coaches in schools. We found in the growing field of private club teams, coaches receive almost no oversight, and the athletes are even more vulnerable. Later we discovered felons convicted of murder, incest and delivering drugs were coaching in the Amateur Athletic Union in Washington and Idaho.
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http://www.aphroditewomenshealth.com/news/20030526004941_health_news.shtml

COACHES WHO PREY ON ATHLETES

Sunday, December 14, 2003 - Page updated at 12:00 a.m.
Coaches continue working for schools and private teams after being caught for sexual misconduct
By Christine Willmsen and Maureen O’Hagan
Seattle Times staff reporters

The bond between athlete and coach can be powerful, and the one between a 15-year-old Port Townsend girl and a 34-year-old basketball coach was especially strong.

The girl, raised in a troubled home, saw Randy Sheriff not only as a mentor on dribbling and jump-shooting, but as surrogate parent, confidant and “the greatest dad in the world.”

Sheriff showered her first with attention, then with flowers and chocolates, then with kisses.

Before long, the coach — a married man with two children of his own — was sending the teenager love notes. By the time she was 16, she says, they were having sex.
People around them suspected as much but looked the other way as Sheriff isolated the girl from her friends and family.

Although Port Townsend school officials believed Sheriff was having an intimate relationship with her, they simply nudged him out of town, allowing him to land a coaching job in the Cascade Mountain burg of Cle Elum, where he was ultimately accused of preying on another girl.

He had to leave that school, too, but continued to coach, this time for girls on elite private teams in the Seattle area.

This is the secret side of the fast-growing world of girls sports. In a yearlong investigation that involved an ongoing court battle with school districts and the state teachers union, The Seattle Times discovered:

• Over the past decade, 159 coaches in Washington have been fired or reprimanded for sexual misconduct ranging from harassment to rape. Nearly all were male coaches victimizing girls. At least 98 of these coaches continued to coach or teach.
• The number of offending coaches is much greater. When faced with complaints against coaches, school officials often failed to investigate them and sometimes ignored a law requiring them to report suspected abuse to police. Many times, they disregarded a state law requiring them to report misconduct to the state education office.
• Even after getting caught, many men were allowed to continue coaching because school administrators promised to keep their disciplinary records secret if the coaches simply left. Some districts paid tens of thousands of dollars to get coaches to leave. Other districts hired coaches they knew had records of sexual misconduct.
• When the state gets involved, its investigations can be as flawed as local districts’. On average, the Office of Superintendent of Public Instruction (OSPI) took two years to investigate a case and sometimes didn’t conduct a single interview with a victim, coach or school official. Often, the state simply dropped investigations, leaving accused coaches with clean records and valid teaching certificates.
• In the growing field of private club teams, coaches can get a job or start a team with almost no regulation or oversight. Men who coach teams sanctioned by the Amateur Athletic Union have been convicted of such crimes as assault, indecent liberties with a child and drug possession.
• With all of these system failures, parents are the last line of defense for female athletes. But too often, parents ignore the warning signs of sexual misconduct. Some parents suspected abuse and did little to stop it, trusting the coaches while doubting their young accusers.

“Unfortunately, everyone has an investment in the silence — the parents, the team and community,” said Sandra Kirby, a Canadian sociologist who studied sex abuse of athletes by coaches. “The measure is, if a coach has had good successes, that’s all they are worried about. They’re ignoring the victims.”

BETTY UDESEN / THE SEATTLE TIMES

Cross country is one of many high-school sports attracting a large number of girls. Last year, more than 3,390 girls statewide competed in the sport. In the state, 43 percent of high-school girls participate in athletics.

NEED FOR COACHES GREATER THAN EVER

A small number of unscrupulous coaches exploits the opportunity
The demand for quality coaching in girls sports has burgeoned since 1972, when Congress passed Title IX, a law requiring that girls be given the same educational — and athletic — opportunities as boys.

Today, the soccer fields and basketball courts of America are nearly as likely to be occupied by females as by males. The number of girls playing high-school sports in Washington has tripled since 1972. Last year, 43 percent of high-school girls played sports.

That doesn’t include the thousands of girls, teenage or younger, who take part in recreational or club teams outside the school setting.

This boom created a nearly insatiable call for coaches, most of whom are men.
Coaching is a demanding profession, with long hours, often low pay and pressure from insistent fans. For most of the more than 20,000 coaches in this state, the reward is the satisfaction of mentoring student-athletes, not only in the skills of a particular sport, but in the values of teamwork, practice and sportsmanship.
But for a small and unscrupulous minority, there is another reward: the opportunity to sexually prey upon their young charges.

Coaching presents a unique opportunity for such misconduct. Coaches work with athletes for hours at a time, often over several years, in unstructured settings such as locker rooms and out-of-town tournaments. Coaches tell them what to eat, how to train and even with whom to associate.

Coaches are generally admired by kids and parents and, like priests, might be the last people suspected of abuse. As a profession, coaching has one of the highest rates of sexual-misconduct complaints, according to Bill Lennon, a Bellevue licensed sex-offender therapist and expert on sexual abuse by teachers.

A study of North Carolina schools found that the No. 1 reason for dismissal of a coach — accounting for 1 in every 5 firings — was not a team’s poor performance on the field, but the coach’s sexual relationship with a student.

The Times analysis shows that Washington teachers who coach are three times more likely to be investigated by the state for sexual misconduct than noncoaching teachers. (Coaches who teach at private schools are not required to have a teaching certificate. Without public records, reporters could not include them in the analysis.)

Misconduct by coaches runs the gamut: a Northshore coach who had sex with a girl for several years and now teaches in Snohomish County; a Davenport coach who paid girls to pose for pornographic pictures and videos; a Lynnwood-area basketball coach accused last week of molesting four girls.

The laws are clear. In Washington, a teacher commits a crime if he has sex with a student younger than 18. For coaches who aren’t teachers, it’s against the law to have sex with someone younger than 16 or with a person younger than 18 if they abuse their “supervisory position” — giving punishment or rewards — to obtain sex.
But the crime is hard to prove and the law rarely used.

In looking at specific cases, The Times found how easily a predatory coach can take advantage of an unsuspecting student, and how easily he can move on to other victims.

VULNERABLE GIRLS CAN BECOME VICTIMS

How a Port Townsend coach took advantage of a troubled teenager

DOCUMENTS

Randy Sheriff came to Port Townsend in 1983 with an impressive résumé. He had led Seattle’s Roosevelt High School basketball team to the 1973 state tournament and later played professional basketball in Europe.

Sheriff coached girls volleyball and boys basketball and taught driver’s education at Port Townsend High School.

In 1988, he took an interest in a 15-year-old girl with long brown hair. He sharpened her basketball skills and talked about her troubles at home. One night, she needed to talk about a fight she had had with her dad. The girl met Sheriff at a picnic table in a park, looking for support.

“He really didn’t seem to want to talk about it,” she said in court records. “He just leaned over and gave me a full-on French kiss.”

Before long, Sheriff was sending her love notes, she said.

“I felt puzzled, like I was falling in love,” the girl said. “He was my lifeline.”
By the time she was 16, she said, she and the coach were having sex in his car, at his house and in motels. Occasionally, she said, he brought along alcohol and marijuana they both used.

(The girl is not being named because The Times generally does not identify people who were sexually victimized. Others did agree to be identified.)

She baby-sat his two children. Sheriff made her his coaching assistant for the Port Townsend boys basketball team and brought her on road trips. She trained with him at his California basketball camp, and he took her to Australia with an adult men’s team.

The relationship took its toll on her. Because Sheriff insisted on secrecy, the teenager distanced herself from family and friends, feeling alone and ashamed.
“If we were driving where people might see us, he would put my head down onto the seat of the car until we got out of town,” she later said in a statement. “That was extremely humiliating for me.”

The girl slipped into depression and had suicidal thoughts. Word of their relationship spread through the high school. Heather Carter, a Port Townsend graduate, said students “snickered” when the pair disappeared into a room off the gym. “Everyone in the school knew they were having an affair.”

Some employees raised concerns with Principal Jim Carter. He talked to Sheriff and the girl, but both denied any intimacy, and the matter was dropped.

PATRICK J. SULLIVAN / PORT TOWNSEND LEADER (1991)

Randy Sheriff was a successful boys basketball coach for several years at Port Townsend High School, taking the team to its first state tournament in 1991. He left the school that year after complaints that he was involved in a sexual relationship with a female student.

But suspicions continued to circulate, and in 1990, Carter sent Sheriff a letter ordering him to stay away from the student.

“There were no more reports and apparently what we did must have worked, because the student left the school district,” Carter said in an interview. “We were satisfied if there was anything going on, we had cut that short.”

But the relationship hadn’t ended. The girl moved in with her mother, transferring to Friday Harbor High School on San Juan Island for her senior year, and played basketball.

After one of her games, coach Vic Woodward questioned the girl about reports that Sheriff had been seen giving her a piggyback ride and kissing her.

She admitted it was true. Woodward “told me it had to stop or he would have to tell someone. He never asked me about it again,” she later told state investigators.

In 1998, she sued the Port Townsend district and Sheriff. A psychologist hired by her lawyer evaluated her, writing in a report: “It appears that Mr. Sheriff took advantage of her vulnerability by requiring her to engage in sexual activity with him in return for his attention and affection. Not only did Mr. Sheriff have a significant advantage over (the girl) due to the age differential, he also enjoyed a power position from his role as a teacher and coach.”

“Don’t have blind faith — I did,” her father said recently. “He is a coach. He is in a position of authority. I didn’t think anything could go wrong.”

The district settled with her in 2002, paying $50,000. Sheriff settled earlier for an undisclosed sum. The victim’s lawyer described school officials’ attitude as “see-no-evil, hear-no-evil.”

In 1991, Port Townsend school officials told Sheriff he was no longer needed as the boys basketball coach despite taking the team to the state tournament.

New school district finds love letter from Sheriff to basketball star

By the next school year, Sheriff found another coaching and teaching job, this time at Cle Elum-Roslyn High School. He coached girls volleyball and softball and boys basketball.

Personnel files are unclear when the new district learned of Sheriff’s intimacy with the Port Townsend girl. However, Cle Elum-Roslyn Principal Jim Stephenson assigned Brian Pendleton, a director of extracurricular activities, to keep an eye on Sheriff.
And before long, Sheriff again was focusing his attention on a girl who was the star of the volleyball and basketball teams.

“It was clear from week two it was already inappropriate,” Pendleton said. “I was angry he had been passed to Cle Elum. Someone passed a problem along and we kept hurting kids.”

In a letter to Cle Elum-Roslyn Superintendent Jake Walker, Pendleton reported that more than 20 parents had lodged complaints about Sheriff in fall 1994: spending unsupervised time with girls after practices, allowing them to drive his car and developing an unusually close relationship with his star player.

In March 1995, administrators were given a love letter, found in the school parking lot, from Sheriff to the girl.

“The way we play off each other is so instinctual, so natural, I can’t help but think about the potential,” Sheriff wrote. “No one cares more for you, no one. Remember I have worshipped you so long — and then had you — now lost you.”

Cle Elum school officials had seen enough. They reached an agreement with the coach and his union: He would quit, and the district would drop its investigation and not disclose his misconduct to potential employers.

Pendleton, currently principal of Walla Walla High School, said he is angry with how he and district officials handled the case.

“I am a little disappointed in myself,” he said. “You are supposed to call the cops. I probably should have.”

Cle Elum officials sent the sexual-misconduct complaint about Sheriff to the state superintendent in 1995.

After four years of investigating the problems in Cle Elum and Port Townsend, the state decided to revoke Sheriff’s teaching license, concluding he had sex with a student and sent love letters to another. At that point, Sheriff voluntarily gave up the license.

But that wouldn’t stop him from coaching.

Pushed out of public schools, coaches start their own private teams
As the participation in girls sports has exploded, so have the opportunities for college scholarships for female athletes. Competition for those scholarships has created a new phenomenon: elite club, or “select,” teams for girls.

These teams are big business, with parents paying coaches thousands of dollars to sharpen their daughters’ skills.

Sandy Schneider, a longtime girls basketball coach and assistant athletic director at Lakeside School in Seattle, sees this largely unregulated world as dangerous territory. Unsupervised coaches are traveling with athletes, staying overnight in hotels and spending countless hours individually training girls — for fees of up to $600 a month.

“There are a lot of kids and families in a position to be exploited,” Schneider said.
Roger Hansen, a highly regarded coach and athletic director for Lake Washington High School, explained: “Joe Blow off the street can go out and recruit and say anything and do anything and promise anything to kids and start his own team.”
It was here that Sheriff found his next coaching opportunity.

Shut off from public-school teaching, Sheriff landed positions in the late 1990s with two club teams: the Bellevue Girls Select Basketball team and the Puget Sound Flight.

Going into private coaching is an easy option for coaches with troubled pasts. The Times found at least nine other coaches like Sheriff who had been reprimanded, fired or pushed out of public-school jobs for sexual misconduct but continued coaching for nonschool teams.

Sheriff insists he told the directors of those teams about his past. “I’ve been honest and told them there were allegations, and still they wanted me to coach,” he said in an interview. “They begged me to coach. I’ve been above and beyond reproach in the past 10 years.”

But Dennis Edwards, Puget Sound Flight director of operations, said he didn’t know about Sheriff’s reputation until a parent informed him three years later. Edwards said he gave Sheriff a choice: Quit or tell players and parents about his past.

Sheriff quit but continued to coach for Bellevue Girls Select. Then in May 2000, he was hired by Barbara Berry, a former University of Washington basketball player, to coach The Way to Win, a private basketball program in Maple Valley.

Berry said she had known Sheriff for years, seeing him at coaching clinics, camps and tournaments, and considers him “the best basketball coach I know, strictly from a basketball sense.”

Shortly after Sheriff started, Berry heard complaints about her friend’s tainted history. “Some didn’t come to The Way to Win program because of it,” Berry said. “I would get phone calls about Randy all the time.”

Even after learning about Sheriff’s past, however, Berry didn’t say anything to her players or their parents.

A few months ago, after reporters started looking into Sheriff’s past, he quit coaching for The Way to Win and Bellevue Girls Select. He now works as a motivational speaker. In an interview, Sheriff said: “I’ve had no inappropriate behavior with students. I’ve always denied all the historical allegations.”

INVESTIGATIONS CAN BE LENGTHY

While the process drags on, teachers who coach often hop to new districts. Just how many Randy Sheriffs are still coaching girls is impossible to say. The Times’ investigation found that school districts are hesitant to even begin investigations, and when they do, the burden tends to fall more on the accusing player than on the accused coach.

Even when districts find evidence of abuse, they often simply pass the offending coach on to another unsuspecting district. And when the state gets involved, investigations are haphazard and can drag on for years.

For example, the OSPI took nearly five years to investigate complaints against Mark A. Taylor, now 44, a Bethel School District volleyball coach and science teacher.

Most of that time, the file sat on OSPI shelves. Taylor had been forced to resign in 1993 from Spanaway Junior High after female students complained that he slipped his hand down a girl’s shirt and fondled her breast on the ride home from a class trip to a water park.

By law, school districts are supposed to inform the OSPI when they have “reliable information” that teachers aren’t of “good moral character” or have committed unprofessional conduct.

The state then must investigate and determine whether those teachers should face discipline, up to losing their licenses.

Bethel officials passed their findings along, but the OSPI took so long to close the case — 1,765 days — that Taylor landed another coaching and teaching job at Clover Park in Pierce County and then at Lake Stevens in Snohomish County. Lake Stevens did not know about complaints against Taylor, and records are unclear whether Clover Park knew.

And girls at those schools accused Taylor of always trying to find ways to be alone with them and sexually harassing them.

While the OSPI sat on the case, Taylor’s teaching license expired. The state, following its policy, closed his case without a resolution. In the past 10 years, the OSPI dismissed 12 sexual-misconduct cases because teachers’ licenses lapsed during the often slow-paced and incomplete investigations.

But Taylor immediately applied to renew his lapsed license.

At first, the OSPI stated it would give him one, but only if he went on probation for four years and told future employers about his misconduct.

Faced with a legal fight from Taylor’s union attorney, the OSPI instead gave him a written reprimand, telling him not to sexually touch or harass girls again.
Taylor taught at Covington Middle School in Vancouver, Wash., for the 2000 school year. He now has a post-office-box address in Washington, D.C., but it’s unclear if he is teaching.

LESS OVERSIGHT IN PRIVATE SPORTS

Confused young girls often don’t recognize what’s happening until it’s too late. Most shocking, perhaps, are cases where officials and parents have reason to suspect problems with coaches but look away.

Glen Whitworth had already been let go from two positions coaching gymnastics. In the Puyallup School District, an assistant coach complained that Whitworth constantly made sexual innuendoes to the girls. In Federal Way, at Gymnastics Unlimited, girls as young as 9 told the gym’s owner that Whitworth talked about sex with them.

But these complaints didn’t stop some parents from helping Whitworth open a gym in the Pierce County town of Sumner.

“I couldn’t believe people left here to go be with him,” said David Mackey, who had fired Whitworth from Gymnastics Unlimited. “I was thinking the parents would keep him in check.”

This time, Whitworth had no boss. And this time, he went a lot further.
When one petite, 13-year-old gymnast met Whitworth at his new gym, she looked up to him from the start.

“You trust your coach,” said the girl, now 26 years old. “You get up on a four-inch beam and you start to do a flip and if you miss, they’re going to catch you. We, like, thought he was god. We worshipped him.”

By the time Whitworth invited the girl to a slumber party at the gym, he had control of her emotionally. That night, he pulled her to him and, with other girls sleeping nearby, forced her to give him oral sex, according to a police report. Then he ordered her to go back to sleep.

The girl was confused, knowing at some level that Whitworth’s actions were despicable, but at the same time feeling she was “chosen.”

A week later, he put her on his team. “I was excited because I got to be on the team with the girls that were really good and everyone in the gym looks up to those girls,” she said.

So when Whitworth encouraged her and another girl to stay late with him at the gym and drink liquor, she found herself going along. Later, he showed them pornographic videos.

Ultimately, the girl was having sex with her coach almost on a daily basis.
She was a typical target — lacking a father figure and having low self-esteem. “I had no ability to say no,” she recalls. “I was a loner. I felt like I wasn’t an understood person.”

After graduating and leaving Sumner, the girl unburdened herself to a friend, who urged her to call police.

Whitworth was arrested and convicted of two counts of third-degree rape of a child.
Even with that record, there’s nothing stopping Whitworth, or any other registered sex offender, from setting himself up again as a coach.
Lakeside coach Schneider can’t believe it. “My question is, who’s overseeing these people?”

Christine Willmsen: 206-464-3261 or cwillmsen@seattletimes.com
Maureen O’Hagan: 206-464-2562 or mohagan@seattletimes.com

EXAMPLES OF CHILD ATHLETE ABUSE SYNDROME (CAAS)

EXAMPLES OF CHILD AND YOUTH ATHLETE PHYSICAL AND PSYCHOLOGICAL (EMOTIONAl) MALTREATMENT, ENDNAGERMENT AND SEXUAL ABUSE, OR CHILD ATHLETE ABUSE SYNDROME (CAAS) :

A. CHILD AND ADULT ATHLETE PHYSICAL MALTREATMENTM ENDANGERMENT AND ABUSE

• Kicking, punching, slapping, hitting, grabbing, head butting and other forms of violent physical contact to athletes
• Non-accidental, Preventable Death of a player while under the supervision of a coach.
• Withholding drinking water.
• Practicing causing extreme exertion of the players and Rhabdomyolysis
• Extreme exertion practicing in dangerous heat conditions when the heat index is severe enough for heat stroke. A heat index of 94* or more and extreme exertion of athlete
• Practicing or Playing in any Harmful Dangerous Athletic Environment with Air Alert and increased ground level Ozone.
• Mismanagement of Injuries
• Mismanagement of Concussion
• Cheerleaders improper protection and supervision
• Lack of pre-participation physical exams
• Hazardous playing fields and courts
• Conditioning and training errors
• Lack of, improper, poorly fitted or inadequate safety equipment
• Playing while injured or overtired. Pressure to play injured
• Declining fitness levels of athletes
• Grouping teams by age instead of size resulting in miss matches
• Poor nutrition of athletes
• Improper techniques during practice and play (e.g., in tennis, improper swing can lead to tennis injury)
• Practicing in stormy Weather conditions and lightening injury
• No warm up or stretching, Growth -(e.g., bones grow faster than ligaments and tendons; inflexibility can lead to injury)
• Lack of sport rules and officials
• Causing players to have physical injury and substantial physical pain and impairment of physical condition’
• Coach inflicts or allows to be inflicted upon the player physical injury by other than accidental means;
• Coach creates or allows to be created a risk of physical injury to the player by other than accidental means
• Non-accidental Physical Injury to a child or an adult athlete that causes substantial physical pain or any impairment of physical condition.(Non-accidental – Preventable Physical or mental mistreatment ) Example : Death from dehydration
• Death from faulty equipment, quadriplegia from faulty technique

Causing athletes to have physical injury and substantial physical pain and impairment of physical condition (cause - to make something happen. the reason something happens. A cause implies what is called a “causal connection”)

Example: Coach hits an athlete with a fist and breaks the athlete’s tooth. Coach throws an athlete to the ground, breaking his arms Coach hits, slaps, kicks, grabs and shakes an athlete

Coach inflicting or allows to be inflicted upon the athlete physical injury by other than accidental means; (Inflict -To cause something unpleasant to be endured; To deal or dish out something punishing or burdensome )

Example: Excessive Running causing stress fractures or other injuries

Coach creates or allows to be created a risk of physical injury to the player by other than accidental means;(Create -To cause to exist; bring into being. To give rise to; To produce)
Example: gymnastics coach punishes athlete with an excessive hand stand and the athlete breaks her wrist.

Coach fails to refer the athlete to a physician after the athlete collapses during practice and the athlete later dies in practice form a cardiac condition.

Coach instructs athlete to re-enter a game after a concussion and on re-concussion the athlete sustains permanent cognitive disability.

Coach instructs a player to re-enter a game with a severe knee injury and the athlete sustains permanent injury.

B. PSYCHOLOGICAL (EMOTIONAL) MALTAREATMENT, ENDANGERMENT STRESS INFLICTED, CAUSED OR CREADTED OR ALLOWED TO BE INFLICTED, CAUSED OR CREADTED BY THE COACH:

• Terrorizes the Athletes
• Regularly using profane derogatory language that lessens the character, ability, humanity or reputation of an Athlete
• Regularly using public embarrassment and humiliation on his/her athletes
• Is disinterested in the feelings and sensitivities of his/her players
• Rarely uses praise or positive feedback
• Is a yeller
• Demeans his/her athletes
• Plays “head games” with his/her athletes
• Is personally dishonest and untrustworthy
• Creates a team environment based on fear and devoid of safety
• Is never satisfied with what his/her athletes do.
• Is overly negative and a pro at catching athletes doing things wrong
• Plays NIGYYSOB. the “Catchin Game”. Now I got you you SOB. Tries to catch an athlete in an error so punishment can be implemented.
• Is more interested in his/her needs then those of his/her players
• Over-emphasizes the importance of winning. Win-at-all-costs.
• Tends to be rigid and over-controlling, defensive and angry
• Is not open to constructive feedback
• Uses excessive conditioning as punishment Can be physically abusive
• Blindsides his athletes with physical strikes, fists, forearms.
• Non-accidental Physical Emotional to a child or adult athlete means substantial emotional pain or any impairment of psychological condition.
• Ignores his/her athletes when angry or displeased
• Is a bully (and therefore a real coward)
• Coaches through fear and intimidation
• Is a “know-it-all”
• Is a poor communicator
• Only cares about his/her athletes as performers, not as individuals
• Consistently leaves his/her athletes feeling badly about themselves
• Kills his/her athletes’ joy and enthusiasm for the sport
• Is a bad role model
• Is emotionally unstable and insecure
• Earns contempt from players and parents
• Coaches through guilt are masters of DENIAL!!!!!
• Belittling limits the athlete’s potential by limiting the athletes own sense of his or her potential.
• Corrupting teaches athlete to engage in antisocial behavior and the child athlete grows up unfit for normal social experience.
• Cruelty to athletes makes all areas of learning be affected - social, emotional, and intellectual development are hindered. Child and adult athletes need to feel safe in order to learn to form healthy relationships.
• Extreme Inconsistency by the coaches means that the coach is inconsistent in his or her response to the athlete, the athlete cannot learn what is expected from the start, and all areas of learning can be effected throughout the child and adullt lifespan.
• Harassment scares the athlete, and repeated exposure to fear can alter the athlete physically, lowering their ability to deal with other stressful situations.
• Ignoring an athlete deprives the child and adult athlete of interactions necessary for emotional, intellectual and social development.
• Lack of control can cause anxiety and confusion in athletes and can lead to a variety of problematic behaviors as well as impair intellectual development.
T
errorizing, like harassment, evokes a stress response in athletes. Repeated stress response alters the athlete physically, lowering their ability to fight off disease, increasing their risk for many stress-related ailments. Aside from the physical affects, a athlete living in terror has no opportunities to develop anything other than unhealthy and anti-social survival skills.

Emotional abuse is the core of all forms of abuse, and the long-term effects of child and adult athlete abuse stem mainly from the emotional aspects of abuse. The psychological aspect of most abusive behaviors defines them as abusive. Despite the fact that the long-term harm from abuse is most often caused by the emotional aspects of the abuse, emotional abuse is the most difficult of the forms of abuse to substantiate and prosecute. Actual physical injury is often required before the authorities can step in and assist an athlete. The effects of abuse are very similar to symptoms of many mental and physical disorders, which makes identifying emotionally abused athletes difficult.

C. SEXUAL ABUSE OF ATHLETES

Center for Sports and the Law; The following are the 4 elements of negligence, Coaches Report - Winter 2003 , Volume 9 Number 3
Part II: Dealing With Violence as a Legal Issue
The four elements of coaching negligence are:
1. a duty of care is owed;
2. the duty imposes a certain standard of care;
3. an injury or damage occurs;
4. and the damage or injury is as a result of a breach in the standard of care.

References:
Athlete Safety 1st, CAPPAA Research
Dr. Alan Goldberg, “Coaching ABUSE: The dirty, not-so-little secret in sports”
Dr. G’s FREE Mental Toughness Newsletter, Competitive Advantage, see link

THE GREAT COACH

THE GREAT, MENTOR ,CREDIBLE, TRUSTWORTHY COACH

Football Coach Blanton Collier was a Great, Mentor, Credible, Trustworthy Coach.

He recruited Football Student-Athletes, men of character and stressed academics at the University of Kentucky.

How is it that he continues to have the best Kentucky football record against Tennessee of all coaches including Bear Bryant?

How was it that Coach Collier had so many assistant who were disciples and all star, successful coaches?

How was it then that Coach Collier was removed as head coach after the 1961 season? That was a very perplexing question.

People Magazine February 04, 1974 “University of Kentucky football fans were unhappy with Coach Blanton Collier in 1959, and they wrote a lot of letters complaining and asking that he and his incompetent aides be gone. The staff was gone by 1961.”

“Of the eight coaches, exactly eight went on to success in pro football, five of them becoming NFL head coaches. Ther were Ed Rutledge, an NFL scout; Howie Schnellenberger, head coach at Baltimore; Ermal Allen, assistant coach at Dallas; Collier, who succeeded Paul Brown at Cleveland and won an NFL championship; Don Shula, of whom you may have heard; John North, head coach of New Orleans; Bob Cummings, his assistant; and Bill Arnsparger, who is taking over the New York Giants. Another Collier assistant, Chuck Knox, was on the staff in 1961 but not in 1959. He was just named Coach of the Year following his first season with the Los Angeles Rams. Fired anybody else lately, Kentucky?”

Coach Bear Bryant claimed that he preferred the “lesser” player as compared to the student athlete that his perennial rival Coach Bobby Dodd of Georgia Tech preferred.
Coaches Bryant and Dodd had that discussion. Bryant, who described himself as a field coach rather than an x and o coach, believed he was more successful motivating the “lesser” player to win football games. The lesser player feared returning to the cotton fields in the early days of Bryant’s career and would do anything to stay and play football.

In Georgia Tech Sports, October 22, 2004 article by Bill Curry -
“We were coached by our own living legend, “The Gray Fox”, Bobby Dodd. He and Coach Bryant were longtime friends, and the Alabama coach was fond of saying, ‘When I look across the field on game day I would rather see anybody other than that damn Dodd. He can beat you with his brain.”

“Coach Dodd was a General Bob Neyland disciple and understood the wisdom of ball security, field position, and error-free football better than anyone else in his era. He also made public reference to the fact that he wanted his boys to have fun playing football and refused to allow us to scrimmage during the season. Rival coaches found this appalling and said so. In that era football was supposed to be a daily gutcheck, not fun.”

On the other hand, the daily gutcheck was playing and practicing out of fear. Not playing for the love of the game. Playing out of Fear is playing in response to threats and dangers. Fear is connected to pain. Fear is a survival mechanism. Fear results because of a specific, strong, negative stimulus from interaction with their coaches and their sports participation environment. Fear is the key to abusive coaches:

Propaganda. Abusive Coaches threaten:

Fear of returning to poverty
Fear of the Coach
Fear of God,
Fear of being called a “quitter”
Fear of disappointing father, family, and community,
Fear disappointing the high school coach and school,
Fear of becoming shunned and ostracized in hometown
Fear of the unknown.

By Mark Story / Herald-Leader Sports Columnist, Nov 23, 2008

“I came to work for the Lexington newspaper in 1990. In that time, I’ve never seen a UK win against UT on a football field. It’s now 23 games since anyone has seen Kentucky beat Tennessee at football. Yet for a stretch of the 1950s, Adolph Rupp’s basketball Cats went a tidy 15-0 against the Orange……

During the same period, UK football — with Blanton Collier coaching Kentucky for all but one of its victories — went 5-2-1 against the Vols. “It was amazing,” says Kay Collier-McLaughlin, the middle of Blanton and Mary Forman Collier’s three daughters. “Beating Tennessee meant so much to Kentuckians. “The energy before those games and at those games and after those games, it was incredible.” Commercial flights to Mars seem more likely than another prolonged period of Kentucky football dominance over the Rocky Toppers……

So I asked Collier-McLaughlin, who wrote a biography of her father, Football’s Gentle Giant: The Blanton Collier Story, what she remembered from her Dad’s days as a Big Orange killer. “The Beer Barrel exchange used to be an amazing thing,” she said of the symbol that used to go annually to the UK-UT winner. “After we’d won several years in a row, Tennessee got frustrated and would try to steal it.

“So, the week of the game, the job of the UK freshmen was to guard the Beer Barrel.” To put in perspective how unique in Kentucky football history was Blanton Collier’s hold over Tennessee, consider:

■ In his tenure at Kentucky, Bear Bryant went 1-5-2 against Tennessee. Collier, Bryant’s successor, went 5-2-1.
■ Since UK axed Collier after the 1961 season, Kentucky has only beaten Tennessee in football six times.

After Lexington, Collier went on to coach the Cleveland Browns to the 1964 NFL championship. Browns fans remember Collier’s tenure as a golden age of Browns football.

He remains the last head football coach at Kentucky to leave the school with a winning record (41-36-3). Collier died in 1983. Those who believe in karma see UK’s continuing futility against Tennessee as payback for dismissing the only coach in modern times who could consistently beat the hated Volunteers. “People have said that to me over and over and over again,” says Collier-McLaughlin.

The great all-pro running back Jimmy Brown of the Cleveland Browns said of Coach Blanton Collier, ” I was prepared for his football genius……but I wasn’t prepared for his humanity”.

A Great Coach must be a Credible Mentor Coach as well as knowing the sport he or she coaches. Getting athletes to play for a coach involves the Trust factor. Players Trust a Great Mentor Coach.

Athletes rely on Coaches to frame their game play, so that the athletes will not suffer undue injury and harm. They count on the Coach to teach them the right way to perform and correct techniques during the game and practice and the correct way to manage their conduct and behavior. The Great Coach prepares the athletes for pressures from inside and outside the program on the more advanced school level.

Coaches are in special professional positions and in a category of their own. They are in positions of power over young and adult, vulnerable players. They influence the players everywhere, both in and out of the playing environment.

Coaches must win games while developing athletes’ characters. After a period of time, Coaches who do not succeed at both, are not tolerated. Sometimes in desperation to succeed they commit crimes against players, the school and society. These Coach dementors who maltreat the Athletes are the exception, not the rule. There are many Great Coaches in the United States, who do not get the credit they deserve.

Coach dementors are the result sometimes of pressure to win. Few parent coaches would recommend their own children to coaches who employ emotional and physical punishment as a means to winning.

Lombardi said “winning isn’t everything … its the only thing”. Few would accept coach dementors as the means to that end. Winning-at-all-costs is the modus operandi of some Coaches and schools. Many of their players are abused. Some Schools turn a blind eye to abusive Coaches. Winning is not the “only thing” when players are abused.

The purpose of sports should be to assist the growth of athletes, expand their knowledge and develop their potential. Sports is not about just producing athletes but building young men and women into our leaders of tomorrow. Unethical, dishonest, immoral behavior should not be tolerated for the sake of winning sports competitions. The dictum is often misrepresented.

Sport builds good character……only when good characters are coaching the sport.
Coaches can dramatically influence the lives of athletes. The Coach must be a mentor, leader and role model. Great Coaches teach their athletes the values of life and living. A Great Coach can mentor a player into a star, role model and a hero for many generations.

A mentor is a more experienced person who is an expert in the sport. The Coach will become a trusted friend, counselor, and teacher of the less experienced athlete. Great Coaches prepare a players athletic career, academics, education and employment opportunity. The Coach is a senior who is wise, influential, trusted and the players’ supporter.

The Mentor Coach is a teacher, guide, counselor, sponsor, advisor, and role model. The player learns athletic skills and knowledge about the game. The Coach develops a lasting open relationship with the player by listening to and being attentive to the players’ concerns and needs.

The Coach motivates the player with encouragement and support. Frequent positive feedback during practice and games builds the players’ self-esteem and boosts his or her morale.

A sense of accomplishment results. Athletes who are always in the dog house with the Coach will not be successful. Positive, constructive feedback, will reinforce behavior and result in the growth of the player and the team.

If you look and concentrate, then you will see. Blanton Collier said if you don’t know where you are going you will never get there. As a UK quarterback, we had a drill in which we practiced our eye movements as part of the timing of the “West Coast Offense” which Coach Collier has been credited.

Athletes goals should be within reach, foreseeable and attainable. The Coach Mentor will show the player where he or she is going.

As a role model, the Coach Mentor is a living example of the conduct and athletic knowledge, as demonstrated. The Coach Mentor for the Athlete is supportive, encouraging and patient. The Great Coach is respected by the players and his coaching peers.

A Coach Mentor is genuinely interested in the players, has the best interest of the player at heart and has good people skills with players, colleagues and even the media. As an effective teacher and motivator the Great Coach will inspire the players to greatness.

The core of coaching is trust. Trust is achieved from the Coaches’ honesty, integrity, knowledge of the game, guidance, inspiration and motivation. Nothing can be accomplished without trust. Lack of trust breeds fear, uncertainty and doubt. Relationships and teams are torn apart from lack of trust. The more the trust the more the victories.

Athletes will run through the proverbial brick wall when they trust their Coach Mentor. When Coaches talk about toughening-up their team and athletes, they must realize that trust by players of the Coach is as tough as it gets and the result of earned concern for the Athletes, not abuse. Coach Mentors should be the schools’ Coach search objective. Players, parents and society should beware the Coach Dementor and insist on better.

As the result of an ideal Coach Mentor, the player will take pride in his team and his Coaches. The Athlete will understand his mission and role as a player and become a better team player and a better role model and mentor in society. Victories will be certain.

Another Great Mentor Coach, Bill Arnsparger, former assistant to Collier at UK, in his book Arnsparger’s Coaching Defensive Football said that Coach Blanton Collier taught him a famous, great quote

” you can accomplish a lot of things if you don’t care who gets the credit”.

SPORTS 911 EMERGENCY ACTION PLAN

•Assessment: evaluate level of consciousness, orientation in time, place and person, respiration/breathing, pulse, blood pressure, temperature.

•Cause, signs, symptoms and types of emergencies: Emergencies include injuries and illnesses such as diabetic hypoglycemia, dehydration, heat stroke, cardiac arrest, heart attack, seizure, cerebral vascular accident/stroke, hemorrhage, lacerated liver, ruptured spleen, collapsed lung and broken ribs, traumatic brain injury, concussion, fractured skull, cervical, thoracic and lumbar spine injuries All categories must be included in the plan.

•Team of responders: includes the Athletic Team Internal Responders: coaches, trainers, team physician / nurse, designated AED responder, record keeping responder to record emergency event, communication-telephone operator responder, maintenance responder to open door or gate and meet the EMS and the External Responders: EMS, police, fire department, hospital and physician / nurse.

•Proper training of the responders and ability to use the equipment

•Properly functioning equipment for the emergency event that has been satisfactorily maintained. An emergency station area must be designated. All working, maintained equipment must be at the emergency station. The minimal equipment must be: tourniquet, first aid kit, eye wash, flashlight, seizure bite block, variety of splints, icy kitty pool for water with hose and 2 large chests of ice, automated external defibrillator, and fire extinguisher.

•Communication among responders: A working phone must be kept at the emergency station on the practice field, stadium, or arena. The entrance for EMS should be designated and keys to that entrance, if applicable, kept with the phone. Emergency numbers for EMS, Team physicians and family numbers should be kept with the emergency phone. The phone communication-telephone operator responder should call all the External Responders including the family.

•Follow up: the record keeping responder should complete a form and self report the emergency event to school officials. Name, address, family phone numbers, mother and father’s name, injury, response, transport of athlete and result.

•All emergency records and sports related injuries must be reported to the KMA, KHSAA, Kentucky Joint Committee on Health and Welfare or the Kentucky Cabinet for Health and Family Services, or another health related governmental department for accurate sports related statistical data collection.

•Continuing Education for responders. All responders must have continuing education about the Sports 911 Emergency Action Plan.

Reference:
1. Building Emergency. Action Plan. The Gatton College of. Business & Economics Building. 550 S. Limestone Street. CALL 911 or. UK Police Department 911
2. General Guidelines for Developing Emergency Action Plans, KHSAA, Kentucky High School Athletic Association
3. National Cheer Safety Foundation

PREDISPOSING RISK FACTORS FOR HEAT ILLNESS AND STROKE

EXERTIONAL HEAT STROKE

LESSONS LEARNED FROM FATAL EPISODES OF HEAT STROKE

Prepared by Stephen T. Hougen, M.D., F.A.C.S., GETAC Injury Prevention Committee, August 19, 2009(GETAC - Governor’s EMS & Trauma Advisory Council, Texas Department of State Health Services)

There are no new lessons to be learned about heat stroke, only new athletes, coaches, trainers, and parents to educate. There are no new events, just the same well-known circumstances that are repeated every year with new, unwary victims. At least 21 young athletes have died from heat stroke during the last several years. (30, 31)

The deaths of Korey Stringer, the Minnesota Viking’s Pro Bowl offensive lineman, on August 1, 2001 and Eraste Autin, the University of Florida’s freshman who collapsed July 19, 2001 after a summer training session and spent six days in a coma before dying, are only two of many widely publicized examples of tragic, but preventable, deaths. We may also recall Matthew Thomas, the 14 year old Victoria Texas High School freshman, who succumbed shortly after football practice during a 92-degree afternoon on August 12, 2003, 17 year old Chris Stewart from Oklahoma City who died of heat stroke in August 2005, (21-28) and Max Gilpin, a 15 year-old Louisville, Kentucky player who collapsed and died when his temperature rose to 107 degrees following a series of wind sprints called “gassers” on a 94 degree day in August 2008. (48, 49, 50, 51, 52, 53)

The typical heat stroke victim is usually not well-acclimatized to the Texas heat. It should be no surprise that student athletes who have spent the summer watching TV and playing video games in the comfort of their air-conditioned homes may not be physically prepared for exertion in the heat. (6, 17)

Overall, however, student athletes are extremely motivated, perhaps sometimes even overzealous, individuals who may push themselves beyond their level of endurance and heat tolerance in their attempt to excel in their sport. (17,19,32,43) During team try-outs an athlete may feel pressured to perform beyond his capability in the heat, ignoring signs and symptoms of impending heat-related illness.

When the brain signals that something was wrong, the athlete can override his brain and keep exerting himself. A competitive athlete is not going to voluntarily take himself out of the competition, an action which might jeopardize his place on the team. Disregarding his brain’s signals, the athlete consciously continues to participate beyond the threshold of safety. His brain even starts to fail, manifested by confusion and atypical behavior, as he generates more body heat than he can possibly lose. His body simply overheats.

The human body has a thermal regulation system that strives to maintain temperature at 98.6 degrees Fahrenheit. That temperature is the comfort zone in which all human biological systems operate efficiently. (46) The body dissipates heat with radiation, conduction, convection, and from the evaporation of sweat. (2, 43, 46) Radiation transfers heat energy via infra-red waves from a hotter to a cooler source, like the glow from a red-hot branding iron as skin capillaries dilate to increase blood flow causing the skin to become red and hot. Heat transfer through conduction occurs through direct contact with an object such as heat gain by touching a hot surface or heat loss by direct contact with ice packs or cold water immersion.

Convection occurs when a cool breeze flows over the hot surface causing heat loss into the ambient air much like heat leaving the cooling plates of a car radiator.

Finally, the evaporation of sweat also causes heat loss as liquid water turns into water vapor. The cooling effect of sweating islessened by high humidity that prevents evaporation. Sweating is also decreased by dehydration from insufficient water intake, normal respiratory water loss, and fluid losses from vomiting. When fluid losses are great, the body starts to lose intravascular volume—the volume of fluid in arteries and veins. (45)

The pulse rate increases as the heart tries to maintain circulation and an adequate blood pressure. To avoid going into shock, the body closes capillaries to direct blood flow away from the skin, gut, and muscles to more vital organs, such as the brain, kidneys, and liver. (44) When the skin capillaries close, the blood leaves the skin surface. Sweating may stop. The skin becomes cool and clammy and goose bumps may appear. (17, 18, 46) The shunting of blood from the skin is what causes people to feel chilled when going into shock. Vomiting and muscle cramps may occur. (7, 38) The failure of the body’s cooling mechanisms—the radiator effect and the sweating-evaporation process—causes an internal heat surge.

Excessive accumulation of heat energy causes thermal injury to biological systems including breakdown of muscle tissue, rhabdomyolysis, potentially irreversible multi-organ failure, and sometimes death. (2, 8, 9, 12, 16, 17, 32, 43, 46)

Early symptoms of heat injury include: thirst, dizziness, lightheadedness, paleness, headache, poor concentration, missed assignments, irritability, altercations, apathy, weakness, fatigue, and a feeling of being limp. More advanced symptoms include: warm and flushed (red) skin, muscle cramping, nausea, and vomiting.

Emergency symptoms of impending heat stroke include: the appearance of cool and clammy skin, absence of sweating, dry skin, rapid breathing, confusion, a change in personality often perceived as “goofing off” and not following instructions, fainting, and eventual collapse. (2,3,11,12,13,14,17,20,31,43)

Treatment must include immediate rapid cooling in the field with ice packs and cold water, with total body immersion if possible. Restrictive clothing should be removed. Every minute of exposure at high core temperatures causes more tissue damage. Every minute counts in a “heat” attack, much like a heart attack. (31)

Emergency hospital care is needed for anyone who collapses during heat-related exertion, and rapid cooling should begin in the field and continued during transport to the hospital. (1,12,17,31,32,33,43)

Prevention strategies are the main approach to reducing the risk of exertional heat stroke. The following measures are recommended.

1. Gradually acclimatize participants to heat with light work-outs the first week of practice. Most heat strokes occur during the initial few days of practice when athletes are not acclimatized to the exercise intensity and equipment. (9,17,18,31,32,43,46)

2. Provide free, unlimited, unquestioned access to cool, palatable water. (5,19,30,31,43)

3. If a player is thirsty he is already dehydrated. He must be allowed to drink without having to ask permission. Drinking 8 ounces of a balanced electrolyte solution such as found in sports drinks every 15 minutes, up to a liter per hour, is recommended before a player feels thirsty. A single swallow from a squirt bottle is not sufficient fluid replacement. (9,11,12,13,16,31,43)

4. Weigh players before and after practice to verify proper fluid replacement. If players lose weight during practice, they are dehydrated and at risk of compromising one of their chief means of cooling — sweating. (17,20,43,46)

5. Take mandatory breaks in the shade and allow players to remove helmets. (31,43)

6. Bathroom facilities should be available, as their absence may discourage adequate oral hydration by players who may feel embarrassed if they need to urinate
.
7. Although water and balanced electrolyte solutions are helpful, salt tablets are not recommended. (10,11,12,13,14,29) Like drinking seawater, taking salt pills can be harmful. In order to eliminate excess salt the body loses water, water it can not afford to lose during conditions of over-heating. (46,47)

8. Good hydration alone does not prevent heat stroke! Even if one drinks plenty of water and sports drinks and is making lots of dilute urine (a sign of good hydration), heat stroke can still occur if the body generates or absorbs more heat that it can dissipate by its usual cooling mechanisms. (16,17,19,43,46)

9. Exposure to direct sunlight increases the radiant energy absorbed as heat. Test this phenomenon by placing a hand on the hood of a car parked in direct sunlight compared with a car parked in the shade. The air temperature is the same, but the vehicle in the sun is much hotter than the one in the shade. If a practice is held in direct sunlight, the heat index increases by up to 15 degrees F, and those 15 degrees should be added to the heat index given by the National Weather Service to determine the risk of heat-related injury. (2,37)

10. Do not allow any outdoor activity if the heat index is 130 or greater. (37)

11. The above guidelines may vary with the age, weight, and conditioning of individual players. To be on the safe side, in his newspaper column “To Your Good Health” Dr. Paul Donohue recommends suspension of practice if the heat index is 90 or greater (Exertional Heat Stroke, a Preventable Cause of Death, Victoria Advocate, July 14, 2007, page E-5). (35)

12. Monitor players for symptoms of heat exhaustion. (1) A player is unlikely to admit that he is feeling weak or lightheaded. He is unlikely to pull himself out of the practice. A buddy system, like one used by scuba divers, may help one player protect and monitor another. (17,18,31,32,37)

13. If a player is dizzy, lightheaded, not “feeling right” or vomits, he must stop practice immediately and be allowed to cool off in the shade with ice packs and soaked towels, or with a cool water mist and fan, with his uniform removed. Vomiting should prohibit anymore practice that day. Notify the parents so the player is monitored at home and properly fed and rehydrated. (12,13,14,17,31)

14. If a player collapses, or if exertional heat stroke is suspected, a player should be rapidly cooled by immediately removing all equipment and uniforms and immersing him cooled in a tub of ice water until EMS can assume care and transport to the hospital.

It is important to cool first, transfer second. Every minute spent above a body core temperature of 104 degrees F, measured rectally or with an esophageal probe, worsens the tissue damage and increases the risk of death. (2,12,13,14,17,19,20,31,32,43,46) Oral, tympanic membrane, and temporal artery temperatures do not accurately measure core temperatures in this setting. (17,43)

15. Avoid stimulants such as highly caffeinated “energy-boosting” drinks (which have fluid-losing diuretic effects), ephedra, ephedrine, amphetamines, and cocaine, which can cause cardiac rhythm disturbances. (2,12,17,32)

16. Practice during the cooler parts of the day, when the heat index is lowest, preferably less than 90, although practice with a heat index of less than 105 may be more practical and acceptable, with appropriate precautions. (17,43)

17. Do not gauge the intensity of practice by pushing players until they get cramps, vomit, or collapse. Remember that if a player is having one symptom, more are likely to follow, possibly in a rapid cascade of downhill events. (32,46)

18. Heat stroke has occurred in marathon runners in relatively cool temperatures of 60 degrees! (32,33,43) The fundamental principle causing exertional heat injury is the generation of heat faster than the heat can be lost. The result is a harmful rise in body core temperature. A core (rectal) temperature of 104 is very dangerous; at 108 the person is likely to die. (1,2,12,16,17,31,38,43,46)

19. The sickle-cell trait, present in 8% of the black population and also found in people of Mediterranean descent, can pre-dispose an athlete to a sickle-cell crisis during times of heat-related stress. A high index of suspicion is necessary when such participants demonstrate any sign or symptom of illness, such as muscle cramps or abdominal pain. Treatment with immediate intravenous hydration and supplemental oxygen may be life-saving and may prevent damage to vital organs.
(1,15,17,40,41,42,43)

20. Players who are ill with fever, diarrhea, vomiting, or viral illnesses should refrain from exertion in the heat. (17,19,32,43)

21. Create a team effort to prevent dehydration and heat stroke involving the coaches, trainers, administrators, parents, and athletes. (31)

22. Remember that poor concentration, missed assignments, frequent penalties, irritability, altercations on the field, muscle cramps, loss of liveliness and spirit, apathy, and increasing frustration of the players and coaches in the fourth quarter may be prevented by what is done in the first quarter regarding proper fluid and electrolyte replacement. A player’s poor performance may not be due to lack of desire or not wanting “it” enough. Sub-par performance may simply be due to a lack of water and over-heating! (16,19,31,43) Like continuing to drive a car with a dry radiator, engine failure is likely to occur.

23. Consider posting an educational heat stroke poster in the locker room. (39)

24. Refer to the accompanying temperature/humidity chart to determine the heat index, or use the programs on www.zunis.org to determine the wet bulb globe temperature and follow the football guidelines and recommended precautions. (37)

For example, the National Weather Service uses the Steadman Heat Index on the following page to provide hot weather advisories to the general public. Using the table, an air temperature of 90 with a relative humidity of 60% produces a Heat Index of 100. This heat index is associated with a low risk of heat-related illness, but appropriate precautions should be taken because heat injury can still occur. If players are exposed to direct sunlight, however, the heat index in the same conditions rises to 115 degree F, a danger zone for exertional heat injury. (,37)

During practice the coach should ask this question: “Are my players being exposed to direct sunlight casting shadows shorter than their height?” If the answer is “Yes” then add 15 degrees to the heat index chart and take appropriate precautions, such as practicing early in the morning, late in the evening, or inside a gym. (2,37,43)

A heat index of 105 and greater represents a danger zone, and heavy exertion should be avoided. In addition, mandatory breaks in the shade with helmets off and mandatory consumption of 8 ounces of water or a sports drink every 15 minutes should be the rule. A few swallows from a squirt bottle are not sufficient to maintain adequate hydration. Because the judgment of the athlete may be impaired in this setting, the player is unlikely to pull himself out of training exercises.

Therefore, trainers and coaches should be observant, monitor their athletes for any symptoms of heat-related illness, and insist that players be removed and protected from dangerous environmental conditions. Prevention and treatment strategies must be in place. (4,5,17,19,43) Remember the advice of experts: “the cooler you stay, the better you play.” (17,18,19)

Note: Exposure to full sunshine can increase HI values by up to 15° F
Alternatively, add 5° F to the temperature when athletes are exposed to direct sunlight

Green Highlighted Heat Index: 90—104. When the heat index is between 90° F and 104° F, heat exhaustion and heat cramps are possible with prolonged exposure and physical activity. Ad lib access to cool water is necessary. Mandatory breaks in the shade every 20 to 30 minutes and extra fluids (water and/or sports drinks) are recommended. Ice water and cold, wet towels for rapid cooling in the shade should be immediately available. Cooling water mist fans are desirable. Observe players carefully!

Yellow Highlighted Heat Index: 105—129. Practice is dangerous in this setting. Under these conditions, instructional “walk-through” drills with minimal running and no contact should be considered. Ad lib access to cool water is necessary. Mandatory breaks in the shade every 15 to 20 minutes and extra fluids (water and/or sports drinks) are needed. An ice water tub for total body immersion or cold, wet towels for rapid cooling in the shade should be immediately available. Cooling mist fans are helpful.

Red Highlighted Heat Index: 130 and Higher. Outdoor exposure and any type of outdoor practice should be prohibited, as heat stroke risk is very great at this level of humidity and temperature. The body’s ability to cool by convection and evaporation of perspiration is severely impaired. In fact, in this environment the body will passively absorb heat from the ambient air and direct sunlight, and cooling by the sweating-evaporation mechanism is not possible because evaporation does not readily occur. Any exertion under these circumstances produces a high risk for exertional heat stroke.

Prepared by Stephen T. Hougen, M.D., F.A.C.S., GETAC Injury Prevention Committee, August 19, 2009

Heat Stroke References

1. Vertuno Jim, The Associated Press, Longhorns Tackling the Heat: Pill Helping Texas Survive Rising Temperatures, published by the Victoria Advocate, August 15, 2007.
2. Hyperthermia, Wikipedia Encylopedia, October 2006, Retrieved from “http://en.wikipedia.org/wiki/Hyperthermia”
3. Heat Illness, Heat Exhaustion, Heat Stroke. The Nemours Foundation/Kids Health at www.revolutionhealth.com January 3, 2007.
4. Joseph Rampulla, MS,APRN,BC (June 2004). Hyperthermia & Heat Stroke: Heat-Related Conditions (pdf). The Health Care of Homeless Persons pp.199-204. Boston Health Care for the Homeless Program. Retrieved on 2007-02-22 at: http://www.bhchp.org/BHCHP%20manual/pdf_files/part2_PDF/Hyperthermia.pdf .
5. “Are you ready for extreme heat?” Courtesy: Federal Emergency Management Agency, Department of Homeland Security. Available from FEMA at: www.fema.gov/areyouready/heat.shtm. Updated August 20, 2007. This information may have changed or been updated since it was accessed. For the most current information, contact FEMA at http://www.fema.gov/.
6. Scott Anderson “Preventing Muscle Cramping in Football”. Coach and Athletic Director. May 2001. At www.FindArticles.com, 15 September 2007. http://findarticles.com/p/articles/mi_m0FIH/is_10_70/ai_n18611880 E.
7. Randy Eichner “Muscle cramps: the right ways for the dog days”. Coach and Athletic Director. August 2002. FindArticles.com. 15 Sep. 2007. http://findarticles.com/p/articles/mi_m0FIH/is_1_72/ai_n18613963.
8. Maddali Sirish, Rodeo Scott, Barnes Ronnie, Warren Russell, Murrell George: Post-exercise Increase in Nitric Oxide in Football Players with Muscle Cramps. The American Journal of Sports Medicine 26: 820-824, 1998.
9. Ruiz E J, Mitchell I D, Eberman L E, Cleary M A. Severe dehydration with cramping resulting in exertional rhabdomyolysis in a high school quarterback. In Cleary M A, Eberman LE, Odai ML eds. Proceedings of the Fifth Annual College of Education Research Conference: Section on Allied Health Professions. April 2006; 1: 31-35. Miami: Florida International Univeristy. http://coeweb.fiu.edu/research_conference/.
10. Cleveland Minot. Musle Cramp. University of Illinois Medical Center at Chicago: Health Library, at www.uimc.discoveryhospital.com, March 13, 2000; reviewed January 4, 2007. “Salt tablets are not useful and should be avoided.”
11. Texas Children’s Hospital. Preventing Heat Illness. Texas Children’s Hospital: Caring for Your Child’s Health at www.texaschildrenshospital.org, 2005. “Salt pills are unnecessary and possibly dangerous.”
12. Centers for Disease Control and Prevention. Frequently Asked Questions about Extreme Heat. Emergency Preparedness and Response Website at www.bt.cdc.gov/disasters/extremeheat/faq.asp. August 15, 2006. “Do not take salt tablets unless directed by your doctor.”
13. Gillis Rick (reviewer). Heat-Related Illness Can Quickly Become Serious. Healthlink: Medical College of Wisconsin at:
Prepared by Stephen T. Hougen, M.D., F.A.C.S., GETAC Injury Prevention Committee, August 19, 2009 www.healthlink.mcw.edu/article/1031002770.html, June 28, 2007. “Salt pills should not be used without first asking your health care provider.”
14. Taylor-Oring Leslie. Is it Heat Exhaustion or Heat Stroke? Tae Park Tae Kwon Do at: www.eod.gvsu.edu/tkd/newpage22.htm. March 14, 1999. “Give them cool liquids—NO SALT PILLS.”
15. Eichner Randy. Curbing Muscle Cramps: More than Oranges and Bananas. Hot Topics in Sports Nutrition. Gatorade Sports Science Institute, at: www.gssiweb.com/ShowArticle.aspx?articled=619. July 25, 2003.
16. Coyle Edward. Fluid and Carbohydrate Replacement During Exercise: How Much and Why? Gatorade Sports Science Institute, Sports Science Exhange #50, Volume7 (1994), Number 3, at: www.gssiweb.com/Article_Detail.aspx/articleid=23&level=2&topic=2.
17. Eichner Randy. Heat Stroke in Sports: Causes, Prevention, and Treatment. Gatorade Sports Science Institute, Sports Science Exchange #86, Volume 15 (2002), Number 3, at: www.gssiweb.com/Article_Detail.aspx?articleid=597&level=2&topic=7.
18. Eichner Randy. Heat Stroke in Sports: How to Protect Yourself and Help Your Teammates. Gatorade Sports Science Institute, Sports Science Exchange #86, Volume 15 (2002), Number 3 Supplement, at: www.gssiweb.com/Article_Detail.aspx?articleid=597&level=2&topic=7.
19. Murray Robert, Eichner Randy. Preventing Heat Illness: Keeping Athletes from Falling into Danger Zones. Gatorade Sports Science Institute, Sports Science Library at: http://gssiweb.com/Article_Detail.aspx?articleid=570&level=2&topic=7.
20. Casa Douglas, Murray Robert. Sports Science News: Preventing Exertional Heat Illness: A Consensus Statement. Gatorade Sports Science Institute, Sports Science Library, 2007, at: http://gssiweb.com/Article_Detail.aspx?articleid=625&level=2&topic=7.
21. Conrad Mark. Mark’s View: Heat Stroke and Football Practice (A comment on the heat stroke death of Minnesota Viking Korey Stringer). Mark’s Sportslaw News, 2001, at: www.sportslawnews.com.
22. CNN News. Vikings football player dies of heat stroke, at: www.CNN.com./U.S., August 1, 2001. This is a CNN news story about Korey Stringer.
23. Associated Press, Mankato, Minnesota. Vikings tackle Stringer dies from heatstroke, August 2001.
24. The Associated Press, Gainesville, Florida: Florida player Autin dies six days after heat stroke. Volume 101, No. 187, Thursday, July 26, 2001. This article discusses the heat stroke death of 18 year old freshman Eraste Autin who collapsed during a work out in 88 degrees, 72% humidity, heat index of 100.
25. Smith Michael. Football Practice Heat Stroke Deaths Preventable (An article about the heat stroke death of 18 year old Chris Stewart). MedPage Today, Daily Headlines, Oklahoma City, August 18, 2005.
26. Sparks Tara. Death has parents concerned. Victoria Advocate, page 1, August 15, 2003 at: www.nl.newsbank.com/nl-search/we/Archives?p_product=VA&P_t.
Prepared by Stephen T. Hougen, M.D., F.A.C.S., GETAC Injury Prevention Committee, August 19, 2009 This article describes a parents’ safety meeting following the death of 14 year-old Matthew Thomas.
27. Victoria Advocate staff writer. Autopsy not yet released. Victoria Advocate, page 1, August 15, 2003, at: www.nl.newsbank.com/nl-search/we/Archives?p_product=VA&P_t.
28. deLench Brook. To Nineteen Youth Athletes Dying Young. MomsTeam, A Parents Trusted Youth Sports Source, at www.momsteam.com. August 25, 2007.
29. Reddy Vinay. Heat Cramps, Heat Exhaustion, and Heat Stroke. Dr. Reddy’s Pediatric Office on the Web at http://www.drreddy.com, 1/12/07.
30. Williamson David. UNC Warns of Possible Heat Strokes for High School Atheletes, at www.unc.edu//depts/nccsi, 2004.
31. Roberts William. Death in the Heat: Can Football Heat Stroke be Prevented? Current Sports Medicine Reports. (3), 2004.
32. Roberts William. Common Threads in a Random Tapestry: Another Viewpoint on Exertional Heatstroke, The Physician and Sports Medicine. 33(10) 2-5, October 2005.
33. Roberts William. Exertional Heat Stroke during a Cool Weather Marathon: A Case Study. Medicine & Science in Sports & Exercise, Official Journal of the American College of Sports Medicine, pages 1197-1203, January 2006 at http://www.acsm-msse.org.
34. Fighting Heat Stress, at http://fighting_heat_stress,asp.htm.
35. Donohue Paul. Exertional Heat Stroke: A Preventable Cause of Death, To Your Good Health. Victoria Advocate, page E-5, Saturday, July 14, 2007.
36. Jung Alan, Bishop Phillip, Al-Nawwas Ali, Dale Barry. Influence of Hydration and Electolyte Supplementation on Incidence and Time to Onset of Exercise-Associated Muscle Cramps. Journal of Athletic Training 40(2): 71-75, April-June 2005.
37. The Zunis Foundation. How Hot is Hot? How Safe if Safe? At www.zunis.org, April 8, 2007.
38. It’s Hot, It’s Humid, It’s Sunny: Information on Heat and Sun-Related Illnesses. Street Medics, www.action-medical.net
39. Hirsch Larissa. Heat Exhaustion and Heat Stroke: A Poster. This is a handy instructional “Heat Sheet” found at www.kidshealth.com
40. Bergeron Michael F, Cannon Joseph G, Hall Elaina L, Kutlar Abdullah. Erythrocyte Sickling During Exercise and Thermal Stress. Clinical Journal of Sport Medicine. 14(6): 354-356, November 2004.
41. Gallais Daniel Le, Bile Alphonse, Mercier Jacques, Paschel Marc, Tonellot Jean Louis, Dauverchain Jean. Exercise-induced death in sickle cell trait: role of aging, training, and deconditioning. Medicine and Science in Sports and Exercise. 28(5): 541-544, May 1996.
42. Kark J A, Posey D M, Schumacher H R, Ruehle C J. Sickle-cell trait as a risk factor for sudden death in physical training. New England Journal of Medicine. (317): 781-787, September 1987.
43. Binkley Helen M, Beckett Joseph, Casa Douglas J, Kleiner Douglas M, Plummer Paul E. National Athletic Trainers’ Association Position Statement: Exertional
Prepared by Stephen T. Hougen, M.D., F.A.C.S., GETAC Injury Prevention Committee, August 19,
2009
9
Heat Illnesses. Journal of Athletic Training. 37(3): 329-343, July-September 2002.
44. Guyton Arthur C, Hall John E. Circulatory Shock and Physiology of its Treatment, Chapter 24, Textbook of Medical Physiology, Eleventh Edition. W.B. Saunders Company, Philadelphia, June 2005.
45. Guyton Arthur C, Hall John E. The Body Fluid Compartments: Extracellular and Intracellular Fluids, Chapter 25, Textbook of Medical Physiology, Eleventh Edition. W.B. Saunders Company, Philadelphia, June 2005.
46. Guyton Arthur C, Hall John E. Body Temperature, Temperature Regulation, and Fever, Chapter 73, Textbook of Medical Physiology, Eleventh Edition. W.B. Saunders Company, Philadelphia, June 2005.
47. Guyton Arthur C, Hall John E. Regulation of Extracellular Fluid Osmolarity and Sodium Concentration, Chapter 28, Textbook of Medical Physiology, Eleventh Edition. W.B. Saunders Company, Philadelphia, June 2005.
48. Graves, Will. Case of Kentucky Coach puts Football on Trial. The Associated Press. The Victoria Advocate, page C-7, Friday, January 30, 2009.
49. Mahalo.com. Max Gilpin, at http://www.mahalo.com/max-gilpin
50. Louisville News, Homepage. Witness: Teen’s Death was Preventable. August 27, 2008. http://www.wlky.com/news/17315849/detail.html Copyright 2008 by WLKY.com.
51. Konz, Antoinette. 911 Call: PRP player drifted in, out of consiousness. Courier-Journal.com, Louisville, Kentucky at http://www.courier-journal.com/article/20081107/NEWS01/811070437/1008/rss01, November 7, 2008.
52. WLKY.com. PRP Football Player Collapses at Practice, In Critical Condition. http://www.wlky.com/sports/17267086/detail.html. August 22, 2008.
53. WLKY.com. PRP Football Player Dies 3 Days after Collapse in Practice. Louisville, Kentucky. At http://www.wlky.com/health/17280899/detail.html, August 27, 2009.
54. Binkley, Helen; Beckett, Joseph;Casa, Douglas; Kleiner, Douglas; Plummer, Paul. National Athletic Trainers’ Association Position Statement: Exertional Heat Illnesses. Journal of Athletic Training. 2002 Jul-Sep; 37(3): 329-343.
55. Parents’ and Coasches’ Guide to Dehydration and other Heat Illnesses in Children. National Safe Kids Campaign. Adapted from: Inter-Association task force on exertional heat illnesses consensus statement: National Athletic Trainers’ Association. June 2003. Available at: www.nata.org/industryresources/heatillnessconsensusstatement.pdf.
Prepared by Stephen T. Hougen, M.D., F.A.C.S., GETAC Injury Prevention Committee, August 19, 2009

_____________________________________________________________________

How hot is hot enough to cause Heat Illness or Heat Stroke? That is a moving target because Predisposing Factors contribute to Death from Heat Illness or Heat Stroke and abnormal body heat balance.

There are reports of death from heat illness with temperatures in the 70″s. because of these Predisposing Factors. Temperature alone from dehydration from insufficient water consumption might not be the sole cause of heat illness.

An Athlete patient can be diagnosed with heat illness if one of the following is associated with body heat imbalance and increased lethal body temperature while working or exercising in the heat.

Water consumption errors do not always account for all heat illness death. Predisposing Factors for heat imbalance and increased body heat and death from heat illness will only be ruled in or out after autopsy.

The following contributing factors: Reference: William O. Roberts, MD, a sports medicine specialist with MinnHealth in White Bear Lake, Minn

I..ENVIONMENTAL

A..Heat Wave
B..Dangerous Heat Index
C..Increased Ground Level Ozone

II. Pathophysiology Predisposing conditions alter heat balance

1. Increased Endogenous Heat load : Vigorous Exercise or overexertion,
2. Increased Exogenous Heat load
a. Sun Exposure
b. Increased Heat Index
c. Dangerous Air Quality. Increased Ground Level Ozone (mbmsrmd)
3. Decreased Heat Dissipation

a. Exogenous cause
i. Humidity
ii. Occlusive or excessive clothing

b. Endogenous cause
i. Dehydration
ii. Lack of acclimatization
iii. Healed burns
iv. Sunburn
v. Dermatitis
vi. Sweat Gland Dysfunction
vii. See Medications Predisposing to Heat Illness

III. Other predisposing factors for abnormal heat balance

a. Prior Heat Stroke

b. Concurrent infection
i. Upper Respiratory Infection
ii. Gastroenteritis

c. Elderly
i. Myocardial dysfunction
ii. Decreased muscle mass
iii. Decreased skin blood supply
iv. Renal insufficiency
v. Chronic illness

d. Comorbid medical condition
i. Anorexia
ii. Cystic Fibrosis
iii. Diabetes Insipidus
iv. Poorly controlled Diabetes Mellitus
v. Obesity
vi. Hypokalemia

IV. MEDICATIONS

A. Sympathomimetic Medications (alpha adrenergic agonists)

1. Amphetamines
2. Epinephrine
3. Ephedrine
4. Cocaine
5. Norepinephrine

B. Anticholinergics
1. Atropine
2. Scopolamine
3. Benztropine mesylate
4. Antihistamines

C. Diuretics
1. Caffeine
2. Alcohol
3. Furosemide (Lasix)
4. Hydrochlorothiazide
5. Bumetanide (Bumex)

D. Phenothiazines
1. Prochlorperazine
2. Chlorpromazine hydrochloride
3. Promethazine hydrochloride

E. Butyrophenones
1. Haloperidol (Haldol)

F. Tricyclic Antidepressant
1. Amitriptyline (Elavil)
2. Imipramine
3. Nortriptyline
4. Protriptyline

G. Monoamine Oxidase Inhibitors
1. Phenelzine
2. Tranylcypromine

H. Recreational and Illicit Drugs
1. Alcohol
2. Lysergic Acid diethylamide (LSD)

I. Other Medications
1. Beta Blockers
2. Calcium Channel Blockers
3. Lithium
4. Heat Illness Prevention

References
Czerkawski (1996) Your Patient Fitness 10(4): 13-20
Sandor (1997) Physician SportsMed, 25(6):35-40
Barrow (1998) Am Fam Physician 58(3):749
Hett (1998) Postgrad Med 103(6):107
Wexler (2002) Am Fam Physician 65(11):2307

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