Taking the Lead

January 29, 2015
A proactive approach and careful planning are critical for protecting your athletes from heat illness. Here, experts weigh in with the latest advice on beating the heat.
By Abigail Funk

Abigail Funk is an Assistant Editor at Training & Conditioning. She can be reached at: afunk@MomentumMedia.com.


It's a nightmare scenario: During a hot, humid afternoon of two-a-day preseason practices, a sudden silence falls over the football field. No yelling, no helmets crashing together--everything stops. Your heart drops as you race to the collapsed player on the sideline. Almost immediately, you recognize the signs of heat stroke.

Virtually all athletic trainers worry about keeping athletes safe from the heat. Though there are plenty of pro-active measures to take--immediate cooling devices, heat policies, emergency action plans--there is always a lingering concern that one of your athletes could be next.

What are the most important precautions to implement in your program? How do you effectively educate your coaches about heat-related dangers? When can an athlete return to play? How do you separate heat illness fact from fiction?

We asked some of the field's leading heat illness experts to answer those questions and more. They also shared their latest research and provided their take on the recent legal proceedings in Kentucky, where a high school football coach is being criminally charged in the death of one of his players. All the experts agree on one thing: The more educated you are about heat illness, the better equipped you are to guard against it.

What are the main things every program should do to protect athletes from heat illness?
Michael Ferrara: You need to take readings so you know what type of environment your teams are practicing in. At the University of Georgia, we've done one of the few studies that looked at the relationship between the environment and exertional heat injury. One of the trends that emerged suggests that the risk for exertional heat illness increases as soon as the wet bulb globe temperature reaches 82 degrees Fahrenheit. That data has held true for the college football players we've studied for five years now.

Sandra Fowkes-Godek: Athletes need structured acclimatization. You can't just start practicing two or three times a day in August, because players' bodies are not ready for that. The acclimatization process will be different in different areas of the country. Kids in Florida, who live in 90-degree heat all the time, are much more acclimated to that weather than a kid in the northeast who only sees those conditions for two months out of the year.

Jon Almquist: There needs to be an immediate cooling mechanism on the field. You can't rely on having players take off their equipment and sit in the shade. We have a tarp that you can find at any hardware store for a few bucks. When we need it, we unfold it, have the kid lie down with his equipment off, have a few coaches gather up the ends, and pour ice water on him so he is submerged. It's not a fancy cooling tub, but we don't have to fill it and clean it out every day and it has the same effect.

The other thing everyone should have in place is some type of policy approved by the school system saying that when the humidity and temperature reach a specific level, there will be some sort of change in practice. Maybe that means no equipment, or helmets only, or more frequent breaks, but there has to be some accommodation for weather conditions.

Doug Casa: Educating coaches, athletes, and parents is paramount. With parents especially, you have to throw the risks out there. They need to communicate with the athletic trainer if their kid has been sick with the flu for two days. Or if their child has sickle cell trait they are more susceptible to heat stroke, so they must tell the athletic trainer at the beginning of the year. You want the parents on board completely.

How has the standard of care for heat illness changed in recent years?
Scott Anderson: There's a greater trend toward cold water immersion as the treatment of choice. Here at Oklahoma, we have implemented on-field immersion with a cold water tank. If there is any question at all about an athlete suffering from heat stroke, we can cool them immediately instead of having to transport them to the athletic training room.

Casa: We're still fighting the same battles we've fought for years. Heat stroke is 100 percent survivable if the person is cooled right away, and yet we still lose people every year. It's gut wrenching to find out someone died when it could have been avoided if they'd been diagnosed and treated immediately. I think we've been very slow to progress, not just with heat illness, but also in the broader landscape of guarding against all sudden deaths.

What is your take on the criminal case involving Kentucky high school football coach David Stinson, who has been criminally charged in the heat-related death of a player?
Ferrara: It certainly brings the issue of exertional heat illness to the forefront. I think all coaches should be certified in CPR and first aid, since coaches are on the front lines if a catastrophic injury occurs. You always want something positive to come out of a bad situation like this, so I hope we can learn from it.

Casa: I think we're going to see a lot more coaches held liable for their actions in the future. I also think the state legislature acted in a very poor manner after the incident. They focused on requiring medical training for coaches instead of addressing the real issue, which is the need for more athletic trainers to provide competent healthcare. You don't want a coach to be the one treating a child on the sideline in a life-or-death situation. Coaches don't want anything to do with medical work. It's unfortunate the legislature couldn't be a little bolder and say that all schools in the state need to employ athletic trainers instead.

Fowkes-Godek: Coaches have a responsibility to adjust practice by having their players wear less equipment, and they need to monitor athletes for behavior or symptoms that indicate a health problem. But for a coach to be held responsible for the medical care of an athlete is ridiculous. Yes, they need to be educated, but they are not trained the way an athletic trainer is, and shouldn't be expected to make medical decisions. They need to hand it off to an athletic trainer, period.

Anderson: As athletic trainers, we have to be attentive to the potential legal issues involved with our jobs, but that can't determine the way we do things. We need to make decisions based on what's best for the athletes under our charge.

How do you educate coaches about heat illness?
Almquist: We take a proactive approach through mandatory education sessions. We also give our athletic trainers a lot of information on heat illness to share with coaches. The information is discussed with athletes as well, and that's important. If a kid understands the warning signs and can say to an athletic trainer, "Hey, this guy's not looking so good," the athletic trainer can intervene immediately, and that's incredibly valuable.

We've made great progress with our coaches. I no longer hear coaches boasting about how they never had water on the field back when they were playing. If they're saying that at all, it's to acknowledge that we've come a long way and now know we must have water available for the kids.

Anderson: I donít think information about heat illness can be shared often enough. During two-a-days, there are 105 football players on the field, and I only have one set of eyes. If I've educated the coaches and players, that's a lot more eyes that can recognize a potential problem at an early stage.

Casa: Coaches care most about performance, so I've found it works best to explain that their athletes will perform better if they're cool, hydrated, and able to recover between sessions. The athletic trainer has to get and keep the respect of coaches by allowing them to work their butts off trying to win the state championship, but also by keeping their athletes safe along the way.

What is the best way to take environmental readings?
Almquist: We use a wet bulb thermometer, which takes into account the air temperature and humidity, but not the impact of the sun. We're located in Virginia, where if it's humid it's also hazy, so we don't really have direct sun we need to account for. But that doesn't hold true everywhere. In places like Arizona, where it's very sunny, a wet bulb globe thermometer is the best choice. Whatever method you use, I'm a big advocate of having the temperature monitored right on the practice field, because the field could be 10 degrees warmer--or 10 degrees cooler--than what your local radio station tells you.

Casa: I definitely recommend a wet bulb globe over just the heat index, because it takes into account the impact of radiation from the sun. The guidelines on what that temperature means, however, are different depending on where you are. People in Mississippi and Louisiana can handle much higher temperatures than people in Maine.

How can you effectively monitor athletes for heat illness?
Fowkes-Godek: In a perfect scenario, you'd have an intestinal sensor in everybody, but we know that won't be the case for most schools. One way is to use weight charts, where you put athletes on a scale before and after practice to make sure they are rehydrating and replenishing between sessions.

But weight charts can be deceiving if you don't know what to look for. It might seem like eight pounds is a lot of weight to lose during practice, but as long as the athlete comes back the next day at his regular weight, it's fine. Another athlete, however, may only lose four pounds during practice, but if he doesn't come back the next day weighing what he did before, that's something to worry about.

Energy drinks have recently surged in popularity with athletes. Can these products contribute to heat illness risk?
Almquist: We need to make sure people understand all the possible adverse effects of some of these products, including heat illness problems. We don't really know all the effects those chemicals can have yet. It's a problem we're struggling with in our district--in fact, we recently banned energy drinks in athletics completely.

Casa: We could pull 10 energy drinks off the shelf at random, and eight of them might be totally fine and two could pose a problem. It's hard to group them all together in one category. We do know that caffeine can actually improve performance, and if taken in normal doses, it does not dehydrate the body. I'd prefer that athletes who are looking for a boost just get a set amount of caffeine that's not in combination with a million other substances like you might find in an energy drink.

Fowkes-Godek: I worry not just about energy drinks, but also about the supplements kids are taking. We really don't have all the information on these products yet. A specific ingredient in an energy drink or supplement may not be a problem by itself, but in combination with things like a really high glycemic load, ephedra, and intense exercise, it could pose a risk.

When an athlete asks me if a certain product would be bad for them to take, I don't lie and say, "Yes, it's bad, don't take it." I say, "Well, I'm not really sure, but my gut feeling is that a lot of the ingredients in here won't do anything for you anyway, and there is potential to hurt your body, so let's not go there."

When can an athlete who has suffered from heat illness return to play?
Casa: With something like heat exhaustion, I would keep the person out for the rest of the day, and with the recommendation of a physician, consider having a modified practice the next day. With heat stroke, it's a completely different story. We generally recommend that those athletes refrain from activity for a week. They need to see a physician for clearance to begin an extensive rehab process to return to activity. I'm talking about light exercise indoors, then heavier exercise indoors, then heavier exercise indoors with equipment on before even going outside. They can slowly work up their fitness level and acclimatize that way.

Almquist: It will always be on a case-by-case basis with a lot of close monitoring, but you need to know why he suffered from heat illness in the first place. Is it just because he's out of shape? Has he been sick? If so, has he been sick for less than 24 hours, or longer than that? If he had a bad bout with some food last night, he might be okay to play sooner than if he's been dehydrated for a week.

We ask athletes to provide urine samples so we can test their hydration level. This can work really well in conjunction with your wrestling program in particular, since high schools across the country now need to keep track of their wrestlers' hydration to comply with new safety regulations.

What new heat illness research should athletic trainers be aware of?
Fowkes-Godek: What Iím writing and revising right now has to do with the wide range of sodium losses that occur in athletes. One player might lose 10 times more sodium than another player during the same workout session. As part of my work with the Philadelphia Eagles and the Philadelphia Flyers, we've been customizing replenishment programs for our salty sweaters, and we've been very successful with some of the adjustments we've made.

Ferrara: We will be expanding our research on piecing together the relationship between the environment and the rate of injury. In Georgia, 25 high schools have signed on and received top-of-the-line wet bulb globe thermometers to take temperature readings over the next year while also keeping track of heat illnesses. We hope to see if the same trends we saw in the college population hold true for high schools.

Anderson: Screening for sickle cell trait at birth is required across the U.S., but in a recent survey, only 37 percent of parents with a child who has it reported they were told of a positive test. Overall, the rate of athletes with sickle cell trait who don't know they have it is extremely high. Of the 18 football players we found to have sickle cell trait through screening here at Oklahoma, only two of them knew they carried it.

What misconceptions about heat illness need to be cleared up?
Anderson: Not everyone understands that exertional heat illness is more about exertion than anything else. Environment and hydration are certainly factors, but people get too caught up in those areas alone. They create a false sense of security by thinking that as long as their athletes hydrate they're in the clear, when in fact the issue is multi-faceted.

There's also a perception that athletes will always have visible, obvious stages prior to heat stroke, but the initial signs and symptoms can actually be very subtle. A small change in an athlete's mental status, like confusion or an odd behavior response, can easily be missed or misinterpreted.

Fowkes-Godek: Many athletic trainers think a certain core temperature--104 degrees Fahrenheit, for example--means an athlete has heat stroke. But a lot of people actually deal quite well with a core temperature that high and may be completely asymptomatic. There is no cut and dried answer for what constitutes an unsafe core temperature.

Almquist: Too many physicians say that heat illness deaths are always avoidable. Yes, we can do a lot to prevent them, but even if we have all the precautions in place--wet bulb thermometers on every field, certified athletic trainers at every practice, a heat policy--a kid who's been sick for a week and is extremely dehydrated could still come to practice and want to impress the coach, work too hard, and collapse. I would love to say that we'll never have a heat death, but I just don't know that for sure.



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Jon Almquist, ATC, is the Athletic Training Program Administrator for Fairfax County (Va.) Public Schools. He serves as Chair of the Athletic Training Advisory Board with Virginia's Board of Medicine and is a member of the Sports Medicine Advisory Committee for the Virginia High School League (VHSL). He took the lead in developing heat illness prevention guidelines for both Fairfax County Public Schools and the VHSL.

Scott Anderson, ATC, is Head Athletic Trainer at the University of Oklahoma. He is a member of the NATA Inter-Association Task Force on Safety in Football and former Co-Chair of the NATA Inter-Association Task Force on Sickle Cell Trait in Athletes.

Doug Casa, PhD, ATC, FACSM, FNATA, is Director of Athletic Training Education and a Professor in the Department of Kinesiology at the University of Connecticut. He is also the Associate Editor of the Journal of Athletic Training and was a writing group member of both the ACSM and NATA position statements on exertional heat illnesses.

Michael Ferrara, PhD, ATC, FNATA, is Director of the Athletic Training Education Program and a Professor of Kinesiology at the University of Georgia. He is on the Board of Certification's Board of Directors and a member of the NATA Research and Education Foundation Research Committee.

Sandra Fowkes-Godek, PhD, ATC, is a Professor and the Medical Coordinator for the Department of Sports Medicine at West Chester University. She is also Director of the school's HEAT (Heat Illness Evaluation Avoidance and Treatment) Institute, which aims to provide athletes and athletic trainers with unbiased information on thermoregulation and fluid and electrolyte balance.
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