“Exertional heat stroke (EHS) is one of the most serious conditions that occur when excess heat, generated by muscular exercise, exceeds the body’s heat-dissipation rate.

“The consequent elevated body core temperature causes damage to the body’s tissues, resulting in a characteristic multi-organ pathological syndrome, which is occasionally fatal.

“Fatal EHS cases, that occurred in the Israeli Defensce Forces during the last decade according to Minard’s paradigm for evaluation of EHS predisposing factors, aiming to characterize the common features and unique circumstances leading to fatality were analyzed.

“Accumulation of predisposing factors, particularly those concerning training regulations, coupled with inappropriate treatment at site, were found to be strong predictors of a grave prognosis.

“Autopsies revealed an association between the duration and length of exercise prior to EHS occurrence and the extent of pathologic findings.

Strict adherence to existing training regulations may prevent further heat stroke fatalities.

[Fatal Exertional Heat Stroke: A case series, Heller Institute of Medical Research, Sheba Medical Center, Tel Hashomer, Tel Aviv University, Israel. The American Journal of the Medical Sciences (Impact Factor: 1.33). 09/2004; 328(2):84-7. Source: PubMed]

Exercise-induced muscle damage (EIMD) increases heat strain during subsequent exercise-heat-stress, which in-turn may increase the risk of exertional heat illness (EHI) during exercise-heatstress When Behavioral Thermoregulation Standards of Care and Preventions and Signals of Heat Illness Are Ignored. [Medicine and Science in Sports and Exercise, American College of Sports Medicine, Matthew B Fortes et al April 2013]

An example of Exertional Heat Stroke was Marquese Meadow, Morgan State University Football Player, who Died, Aug. 24, 2014. “BALTIMORE (AP) — Morgan State University in Maryland says a football player who was hospitalized after a workout two weeks ago has died. “Television station WBFF-TV (http://bit.ly/1t4HSVZ ) first reported that 18-year-old Marquese Meadow died Sunday.

“Morgan State University spokesman Clint Coleman confirmed the death. He told The Associated Press that Meadow had been hospitalized since becoming disoriented during the workout two weeks ago. Coleman says Meadow had recently been improving but took a turn for the worse Saturday. [WBFF-TV (http://bit.ly/1t4HSVZ )]Died of Football Heat Stroke during workout was ruled Accidental. [August 29, 2014|By Edward Lee, The Baltimore Sun].

Exertional Football Heat Strokes (EFHS) are Not Accidental and 100% Preventable, when all the Standards of Care for the Prevention of Heal Illness are followed. EFHS are not natural and not inherent to the way the game of football is played, because the Prevention Guidelines have not been followed during football practices and games.

“EFHS is a preventable cause of death. Preventing heat stroke deaths in football will take a team effort on the part of all involved in the sport, including the administrators, coaches, and athletes to recognize and treat heat stroke victims without delay.

“The logical prevention strategies and standards of care that must be instituted at all levels of football practice include a heat and humidity cascade linked to allowable work load, including intensity and duration. Within the work-rest parameters, fluid and salt replacement should be accomplished on a combined mandatory and ad libitum schedule to maintain optimal fluid status. The model practice schedule should accommodate acclimatization of the players with special precautions for those who have a history of heat collapse or are at increased risk due to large mass (body mass index > 30).

“Players should have three to five days of conditioning and drills in shorts and T-shirts that could include the helmet after one or two days, and three to five days of helmets and shoulder pads before allowing the full uniform in practice. Pads and helmets should be removed to promote body heat loss when not needed for protection. The amount of uniform should also be tailored to the heat and humidity utilizing a graph, especially in the early season during double sessions while the athletes are adjusting to the heat.

“When reduction strategies fail, early recognition is the key to player survival. A heated brain does not function well, so depending upon the judgment of the athlete with an elevated core temperature is not adequate for heat safety. However, an athlete who complains of not feeling well or not “being right” should be given the latitude to cool or be checked to ensure that the rectal temperature is not elevated above 103ºF. The onset of heat stroke in football players seems sudden and rapid, but reviewing death cases in football heat stroke victims shows some common, although sometimes subtle, indicators of impending catastrophe. Coaches and teammates must be vigilant and feel free to report athletes who are vomiting or who have changes in routine performance.

“I have often made the statement that football is a “brain stem” sport. Not to denigrate the sport, instead to emphasize how much football requires focus and cognitive function to perform well, and to emphasize that many of the routine activities of practice have been repeated so many times by players that they can perform reasonably well even when the brain is not fully engaged or when it is overheated. Determination under duress ‘to carry on’ becomes automatic when the brain stem takes control.

A player who staggers and stumbles, misses assignments in blocking drills, or does not perform to expectation in the heat may not be “goofing off” or “not trying,” but instead may be in trouble with the heat. Coaches and athletic trainers need to look closely at players who are performing below par and evaluate their heat status. In hot conditions, we should institute the buddy system to have players watch out for each other, as with swimming to prevent drowning or with Nordic skiing in the cold to prevent frostbite. This will take some of the pressure off the coaches and allow players to help each other.

“Vomiting is not normal during exercise, especially in the heat. Vomiting occurs because the gastrointestinal tract is no longer working properly and the ingested fluids are not absorbed. Two things happen in the vomiting athlete.
• First and most obvious, sweat losses are not replaced, so the athlete becomes dehydrated and at greater risk for heat stroke, as both sweating and vascular heat transport are decreased.
• Second, the loss of electrolyte through emesis will further complicate the clinical picture and treatment of heat stroke.
• An athlete who vomits in football practice, especially during the first few days of double sessions, should be assumed to have heat injury and is at great risk for heat stroke. • These athletes should never be returned to practice on the same day and should be evaluated by an athletic trainer or physician familiar with football and heat illness prior to return practice on the following day.

“On-site cooling in a tub of ice water to bring the temperature down rapidly is life-saving and practice sites should be equipped with tubs to immerse players who show signs of heat injury or heat stroke. Dr. William Roberts said in his field experience, treating runners with exertional heat stroke in ice water tubs, the rectal temperatures can be reduced from above 108ºF to below 102ºF in 20 to 40 minutes. Heat stroke and heat injury can be identified with a rectal temperature measurement, and if a rectal temperature cannot be obtained it may be best to cool the athlete while waiting for the emergency medical transport team to arrive. When athletes falter in hot conditions, one should consider it a heat attack and cool the athlete immediately in a tub of cold water.”

“The incidence of exertional heat stroke in football practice is reducible with attention to environment, acclimatization, equipment, and hydration; heat stroke death in football practice is preventable with early recognition and on-site core temperature reduction. Recognizing heat stroke before the final collapse requires a change in football attitude and close observation of player performance and well being.

“A prominent coach in the 1950s stated to a player’s father that the practice conditions with no water in the heat were necessary because, “it is war out there on the field,” to which the father of the heat stroke victim replied, “I’ve seen war; football is a sport.” It is time to accept that, as with adding water to the practice sites, it is time to utilize the temperature-humidity scales and acclimatization to protect the players.

[Death in the heat: Can football heat stroke be prevented? by William O. Roberts, M.D., M.S., Sports Medicine Reports, Vol. 3, No. 1, February 2004, Dr. William O. Roberts is on staff of the Department of Family Practice and Community Health, University of Minnesota Medical School, and is also a member of the League’s Sports Medicine Advisory Committee. He can be reached via e-mail at rober037@umn.edu.]

“Although summer is quickly coming to an end as football begins, there are still many hot and humid days ahead. ‘The heat is on’. Those hot, humid days greatly increase the risk of heat-related illnesses in physically active children and adolescents. The review of the types of heat-related illnesses, appropriate first aid, and most importantly, prevention and standards of care:

Exertional Heat Stroke

“Exertional heat stroke (EHS) is a medical emergency that can occur quickly and progress rapidly if not treated. The primary cause of EHS is high-intensity exercise, especially for prolonged periods of time. This can be compounded by wearing equipment, lack of acclimatization, and hot or humid environments. Cardinal signs of EHS are an elevated core body temperature (above 104°F) and altered central nervous system function (change in level of consciousness, collapse, disorientation, incoherent speech, change in personality, convulsions). These may also be accompanied by nausea or vomiting, diarrhea, headache, and increased breathing and pulse.

“A common misconception is that victims of heat stroke will have hot, dry skin; while this may be true with classic (non-exertional) heat stroke, EHS victims will often be sweating profusely. Remember that core body temperature cannot be accurately measured through oral, tympanic, and axillary (underarm) thermometers as they typically read lower than true core temperature. Rectal temperature is considered the gold standard but is not always possible. If you’re concerned that an athlete may be suffering from EHS and you cannot obtain a rectal temperature, activate EMS and begin first-aid.

“First-aid for EHS is simple—full body immersion in cold water (35-60°F) and activation of EMS. This should occur immediately and before transporting the victim to a hospital. Full body immersion can be accomplished in a cold tub, kiddy pool, or shower after removing all equipment and unneeded clothing. The athlete should NEVER be left unattended during immersion and first-aiders should monitor vital signs and level of consciousness until EMS arrives. When the athlete begins shivering (after several minutes), he or she should be removed from the cold water and monitored until EMS arrives. Cool, clear fluids may be given when the athlete is removed from immersion if he or she is fully conscious and able to drink independently. NEVER attempt to give oral fluids to a person who is semi-concious or unconscious.

Exertional Heat Exhaustion

“Exertional heat exhaustion (EHE) is essentially a precursor to exertional heat stroke. It involves a slightly elevated core body temperature (99-104°F) and a decreased ability or inability to continue exercise. There can also be fluid, sodium, and energy depletion components. Other signs of EHE include pale skin, weakness, dizziness, headache, decreased appetite, nausea, vomiting, and diarrhea. The main recognizable difference between EHS and EHE is the altered mental status that occurs with exertional heat stroke.

“First-aid includes removing equipment and unnecessary clothing, moving the athlete to a cool place (air conditioned or at least in the shade), beginning fluid replacement with cool liquids such as water or sports drink, and cooling the athlete with ice bags, fans, and cold towels. If the victim does not begin to recover quickly, activate EMS, consult your primary care physician, or transport the child to an emergency medical facility.

Exertional Hyponatremia

“Exertional hyponatremia occurs when a physically active person suffers a fluid-electrolyte imbalance, namely too much water and not enough sodium in the blood. Exercise in the heat often results in large losses of both sodium and water through sweating. Exertional hyponatremia happens when an athlete does not ingest enough sodium to replace what is lost in sweat, or when an athlete drinks too much fluid without proper sodium replacement. Symptoms mimic those of exertional heat stroke, except that the victim is not overheated. They may include changes in mental status, nausea, vomiting, diarrhea, headache, physical exhaustion, muscular weakness, and disorientation or confusion. Athletes on low sodium diets and those who drink strictly water are particularly at risk. ‘Salty sweaters’ are also at a greater risk—individuals who have a higher sodium content in their sweat. A good way to determine if an athlete is a salty sweater is to have him work out in a cotton t-shirt until it is saturated, remove the shirt while wet, and hang to dry overnight. Once dry, shake the shirt out; if a white cloud appears, the athlete is most likely a ‘salty sweater’. Licking the skin is not as accurate. It is also important to remember that fluid-electrolyte imbalances can occur over a period of days, such as during tournaments and two-a-day practices.

“First-aid for exertional hyponatremia includes transport to an emergency facility or activation of EMS if the athlete’s mental status has changed significantly. This allows medical professionals to determine the level of sodium replacement needed and the best way to deliver it.

Prevention and Standards of Care of Heat-Related Illnesses

“The best treatment for any illness is to prevent it from happening altogether and heat-related illnesses are no exception. Encourage kids to listen to their bodies when it comes to thirst and exercise intensity. New research has shown that drinking to thirst is the best way to ensure an athlete maintains appropriate fluid balance in the body during physical activity. Rehydration should also continue between events or practices. Eating a good diet is very important in hot weather, especially when exercising in the heat for a period of days. Athletes should salt their food generously (unless they have an underlying medical condition or family history of high blood pressure) and choose foods that have high sodium content, such as pizza, soup, and pretzels. This is especially true for salty sweaters. This salty diet can be altered back to ‘normal’ once the weather cools down or athletes aren’t exercising for long periods of time on successive days.

“Frequent rest breaks are important in hot, humid weather to allow the body to dissipate heat and the athlete to drink when thirsty. Athletes should be permitted to remove helmets and other equipment during rest breaks if possible. When exercising in hot weather, ten minute breaks every 20-30 minutes are recommended and athletes should be allowed free access to fluids.

“Gradually acclimating to the heat over a period of two weeks is extremely important and allows the body to make physiological changes and better tolerate exercise in hot environments. If a child is taking medications, consult your primary care physician to determine if they could increase the risk for heat-related illnesses.

“Heat-related illnesses are an inherent danger when exercising outdoors in the summer. But always remember….an ounce of prevention is worth a pound of cure! Hopefully the above information will help you and your young athlete take adequate precautions and have a safe, happy, and healthy summer and fall season.

“Consult your primary care physician for more serious injuries that do not respond to basic first aid. As an added resource, the staff at Nationwide Children’s Hospital Sports Medicine is available to diagnose and treat sports-related injuries for youth or adolescent athletes. Services are now available in five locations. To make an appointment, call (614) 355-6000 or request an appointment online. [When The Heat is On, Sports Medicine Articles, Nationwide Children’s Hospital, 700 Children’s Drive Columbus, Ohio 43205 614.722.2000

NATA (National Athletic Trainers Association) Releasee Executive Summary Of Revised Exertional Heat Illness Position Statement:

“Exertional heat illnesses are largely preventable within the confines of organized sports when appropriate protocols are put into place,” said Douglas J. Casa, PhD, ATC, FACSM, FNATA, chief operating officer of the Korey Stringer Institute, director of Athletic Training Education, Department of Kinesiology at the University of Connecticut and chair of the position statement writing group. [Note: Casa is also a member of MomsTEAM Institute’s Board of Advisors, which is developing best practice guidelines, including on exertional heat illness, as part of the Institute’s SmartTeams Play Safe initiative.

“This includes heat acclimatization, body cooling, hydration, modifying of exercise based on environmental conditions, among other considerations. These guidelines are not just for athletes – they are also valuable for individuals exposed to warm weather environments such as those in the military or individuals whose work necessitates heat exposure.”

“Exertional heat stroke is one of the three leading causes of death in sport (and the leading cause in the summer). The period of 2005 to 2009 had more heat stroke deaths than any other five year period in the 35 years prior. There were 18 deaths from 2005 to 2009; from 2010 to 2014 (still being tracked) there are now an estimated 20 to 22 deaths.[Exertional Heat Illness Executive Statement, From The National Athletic Trainers’ Association]

“Athletes must be tested for Sickle Cell Disease and Trait. Sickle cell trait (SCT) athletes are at risk of suffering a potentially life-threatening condition called exertional sickling, with heat, dehydration, asthma, high-intensity exercise and high altitude increasing that risk. But why do some SCT athletes never suffer from excertional sickling or heat illness while others do (with some cases resulting in death. [Does Genetic Mutation Explain Why Only Some Sickle Cell Trait Athletes Suffer Exertional Sickling? By Lorena Madrigal, PhD, Posted April 23, 2013, USF and Arizona State researchers looking for SCT athletes to answer survey and provide DNA for study (1. Adorno EV, Zanette A, Lyra I, Souza CC, Santos LF, Menezes JF, Dupuit MF, Almeida MNT, Reis MEG, and Goncalves MS. The beta-globin gene cluster haplotypes in sickle cell anemia patients from northeast Brazil: A clinical and molecular view. Hemoglobin2004;28(3):267-271. 2. Lettre G, Sankaran VG, Bezerra MAC, Araujo AS, Uda M, Sanna S, Cao A, Schlessinger D, Costa FF, Hirschhorn JN and others. 2008. DNA polymorphisms at the BCL11A, HBS1L-MYB, and beta-globin loci associate with fetal hemoglobin levels and pain crises in sickle cell disease. Proc Natl Acad Sci USA 2008;105(33):11869-11874. 3. Wajcman H, and Riou J. 2009. Globin chain analysis: An important tool in phenotype study of hemoglobin disorders. ClinicalBiochemistry 2009;42(18):1802-1806.) ]

“Parents and Guardians cannot give consent for Child Athletes to participate in (SRE) that cause serious Physical, Psychological Injuries, Death and Sexual Abuse.

That consent is invalid because Maltreatments, Endangerments and Substandard Supervisory Care that cause these catastrophes are not “reasonably foreseeable hazards”.

Maltreatments and Endangerments that cause these catastrophes are not inherent or natural to the games that are played. “Not Reasonably Foreseeable” [ Kimberly A. Harris, Death at First Bite: 35 ARIZ. L. REV. 237, 248 (1993) See id. at 248 n.104 stating Model Penal Code permits “consent as a defense to serious bodily injury only where such injury is a ‘reasonably foreseeable hazard’ of participation in sports or athletic contests”]

As for adults, “Courts do not permit institutions to waive their responsibility when they have allowed or exercised gross negligence or misconduct that is intentional or criminal in nature.” Such an agreement for Gross Negligence and Intentional Acts would be deemed to be against public policy because it would encourage dangerous and illegal behavior. [Waivers and Releases, USLEGAL: http://sportslaw.uslegal.com/tort-law/waivers-and-releases/#sthash.18jR0ATJ.dpuf]

The Executive Summary of National Athletic Trainers’ Association Position Statement on Exertional Heat Illnesses and An update to the 2002 NATA Guidelines follows:
“Background: This 2014 document is an executive summary update of the NATA 2002 Exertional Heat Illnesses position statement providing revised recommendations and key insights for the management of exertional heat illnesses. The 2014 position statement will be published in the Journal of Athletic Training, NATA’s scientific publication. It covers prevention, recognition and treatment strategies of exertional heat illnesses including exercise associated muscle cramps, heat syncope, heat exhaustion and exertional heat stroke.

“Key Statistics:

• Exertional heat illnesses are largely preventable when appropriate prevention strategies are implemented. These strategies include heat acclimatization, hydration, modifying exercise based on environmental conditions, etc.
• Exertional heat stroke is one of the three leading causes of sudden death in sport. The period of 2005 to 2009 had more heat stroke deaths than any other five year period in the 35 years prior. There were 18 deaths from 2005 to 2009; from 2010 to 2014 (still being tracked) there are now an estimated 20 to 22 deaths.
• Death from exertional heat stroke is 100% preventable when proper recognition and treatment protocols are implemented.


“Prevention of Exertional Heat Illnesses:

• A pre-season heat acclimatization policy should be implemented to allow athletes to be acclimatized to the heat gradually over a period of 7 to 14 days. This is optimal for full heat acclimatization.
• Plan rest breaks and modify the work-to-rest ratio to match environmental conditions and the intensity of the activity.
• When environmental conditions warrant, ensure that a cold water immersion tub and ice towels are available to quickly manage an athlete with a suspected heat illness.

“Recognition of Exertional Heat Illnesses:

• The two main diagnostic criteria for exertional heat stroke are profound central nervous system (CNS) dysfunction and a core body temperature above 105°F.
• Rectal temperature is the only method of obtaining an immediate and accurate measurement of core body temperature in an exercising individual.

“Treatment of Exertional Heat Illnesses:

• The goal for any exertional heat stroke victim is to lower core body temperature to less than 102.5°F within 30 minutes of collapse.
• Cold water immersion is the most effective way to treat a patient with exertional heat stroke. The water should be 35-59°F and continuously stirred to maximize cooling.
• An athlete suffering from exertional heat stroke should always be cooled first (via cold water immersion) before being transported by EMS to an emergency facility.
• An athlete recovering from exertional heat stroke should be closely monitored by a physician or athletic trainer and return to gradual activity.

“UPDATED FINDINGS: Specific recommendations for pre-season heat acclimatization protocol:

• Days 1-2: Single three hour practice OR single two hour practice and single one hour field session; only helmets may be worn
• Days 3-4: Single three hour practice OR single two hour practice and single one hour field session; only helmets and shoulder pads may be worn
• Day 5: Single three hour practice OR single two hour practice and single one hour field session; full equipment may be worn
• Days 1-5: Equipment guidelines for preseason participation only impact days 1-5 of the acclimatization period

“Recommendation of assessing rectal temperature if exertional heat stroke is suspected: Best practices strongly advise the use of rectal temperature for the assessment of body temperature in a suspected exertional heat stroke patient. It is discouraged to use inaccurate devices such as oral, tympanic, etc

“Specific protocol for the treatment of exertional heat stroke: The new guidelines suggest a specific step-by-step protocol for cold water immersion for the clinician to implement with an exertional heat stroke patient. This protocol is backed by research exhibiting a 100 percent survival rate when initiated quickly and properly.

“Identification of approximate cooling rates for an exertional heat stroke patient: While cooling rates may vary, the cooling rate for cold water immersion will be approximately 0.37°F/min. or about 1°F every three minutes when considering the entire immersion period for an exertional heat stroke patient. This provides an approximate treatment time for clinicians if rectal temperature monitoring is not possible during treatment.

“Recommendation of “cool first, transport second”: The current document now states that a patient suspected of having exertional heat stroke must be cooled via cold water immersion for the full treatment time prior to being transported to a hospital. Additionally, the document states that this must be stated in the school’s emergency action plan.

“Substantial revision of tables and figures to provide more of a clinically applicable demonstration including:

• Addition of common risk factors for exertional heat stroke
• Key items to include in a pre-participation physical exam to help identify an athlete who may be predisposed to exertional heat illnesses
• Specific guidelines to implement for a pre-season heat acclimatization policy
• Differential diagnoses for heat illnesses including common signs and symptoms
• Specific guidelines for implementing cold water immersion for an exertional heat stroke patient
• A detailed algorithm for recognition and treatment of exertional heat stroke

“Removal of hyponatremia as an exertional heat illness: Hyponatremia (low blood sodium) was removed from the current guidelines as this condition is not considered to be a true heat-related illness.

“The NATA publishes its position statements as a service to promote the awareness of certain issues to its members. The information contained in the position statement is neither exhaustive nor exclusive to all circumstances or individuals. Variables such as institutional human resource guidelines, state or federal statutes, rules, or regulations, as well as regional environmental conditions, may impact the relevance and implementation of these recommendations. The NATA advises its members and others to carefully and independently consider each of the recommendations (including the applicability of same to any particular circumstance or individual).

“The position statement should not be relied upon as an independent basis for care, but rather as a resource available to NATA members or others. Moreover, no opinion is expressed herein regarding the quality of care that adheres to or differs from NATA’s position statements. The NATA reserves the right to rescind or modify its position statements at any time.[Executive Summary of National Athletic Trainers’ Association Position Statement on Exertional Heat Illnesses: An update to the 2002 NATA Guidelines]

The 4 elements of Negligence and 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.
[Part II: Dealing With Violence as a Legal Issue, Center for Sports and the Law; Coaches Report, Winter 2003, Volume 9 Number 3]

Even OSHA has Standards of Care to Prevent Heat Illness in the workplace. Athletes are entitled to the same Standards of Care in their “workplace”.

Under the General Duty Clause, Section 5(a)(1) of the Occupational Safety and Health Act (OSHA) of 1970, employers are required to provide their employees with a place of employment that “is free from recognizable hazards that are causing or likely to cause death or serious harm to employees.” The courts have interpreted OSHA’s general duty clause to mean that an employer has a legal obligation to provide a workplace free of conditions or activities that either the employer or industry recognizes as hazardous and that cause, or are likely to cause, death or serious physical harm to employees when there is a feasible method to abate the hazard. This includes heat-related hazards that are likely to cause death or serious bodily harm.

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