Jan 29, 2015Facing the Heat
More and more athletic programs are using written policies to govern practices and workouts in the hot, humid months. From getting everyone on board to deciding what rules to set, there are several critical steps to a successful policy-making process.
By Abigail Funk
Abigail Funk is an Assistant Editor at Training & Conditioning. She can be reached at: [email protected]
Almost three hours into the first practice of the 2007 football season, and just minutes before the coach planned to send everyone to the showers, 16-year-old Kenny Wilson collapsed on the field. The junior linebacker at Beckman High School in Irvine, Calif., was immediately put in an ambulance, but he went into cardiac arrest and died en route to the hospital. Speculation ensued that the 90-degree temperature and high humidity that day played a role in Wilson’s death, and a few months later, the county coroner’s autopsy report confirmed that heat stroke was the cause.
Wilson was one of several football players who made grim headlines in recent years after a heat-related death. In February, the National Center for Catastrophic Sport Injury Research at the University of North Carolina released its Annual Survey of Football Injury Research, reporting on data collected through 2007. The report says that since 1995, 33 football players have died from heat stroke, including 25 high school students and five college athletes.
While those numbers suggest the odds of your program experiencing a heat-related death are quite low, they also show that heat illness is a serious threat that warrants serious action. Across the country, athletic programs have helped minimize the risk by implementing comprehensive heat policies, and by updating them regularly to reflect best practices and all available information and resources.
These policies are more than just a set of guidelines spelling out when it’s too hot to practice in full equipment, when two-a-days have to be canceled, and who to call if an athlete is in distress–though they can include all those components and more. A well-designed heat policy is a statement of preparedness and awareness, and a way to show that your program’s primary goal is protecting student-athletes’ health and safety.
“When an athlete dies from a heat-related illness, a lot more scrutiny is placed on school and athletic department policies, and in turn, on athletic trainers,” says Jonathan Stinson, LAT, ATC, Head Athletic Trainer at Steele High School in Cibolo, Texas. “It’s very important to take an active role in developing and refining a policy–to be proactive and not reactive. If you have a policy in place and educate your coaches and players about it, you can avoid a lot of potential problems.”
The first step in crafting a heat policy or revising one that already exists for your school, district, or conference is making sure all the right people understand that a policy is necessary. If sport coaches, athletic administrators, parents, school board members, and student-athletes are not aware of the dangers of heat illness and the effects of working out in extreme heat, you’ll have trouble garnering the support necessary to make the policy effective.
“If I were in a high school setting, I would go to the parent organizations first,” says Sandra Fowkes Godek, PhD, ATC, Medical Coordinator at West Chester University and Director of the school’s HEAT (Heat Illness Evaluation Avoidance and Treatment) Institute. “If you educate parents about the potential problems–such as coaches being too aggressive with workouts early in the preseason–they have a way of making things happen. Parents can be great advocates for athletic trainers in building momentum behind a heat policy.”
What exactly should you educate people about? Jon Almquist, ATC, Athletic Training Program Administrator for Fairfax County (Va.) Public Schools, says a basic review of the published research on heat illness can provide a convincing case to any stakeholder in scholastic athletics. “There are many studies out there to give you scientific support,” he says. “It’s well established that precautions must be taken in extreme heat, or else the end result could be tragedy.” (See “Resources” at the end of this article for some specific information sources.)
Aaron M. Karlin, MD, Pediatric Sports Medicine Specialist with Ochsner Health System in Covington, La., used the awareness-first strategy as the medical advisor for a committee that created a district-wide heat policy in St. Tammany Parish (La.) earlier this year. “Some people in the group, which consisted of principals, assistant principals, a school board secretary, athletic directors, and parents, had misconceptions about what heat illness is,” he says. “Everybody knew on some level that practicing in the heat is dangerous and there needed to be certain precautions in place, but they were not educated about the real effects of extreme heat.
“So for our first couple of meetings, I brought in 20 or 30 different research articles, reports from the American College of Sports Medicine and the NATA, and examples of policies from other states,” Karlin continues. “I bombarded the committee with information to show them the reality of heat illness. If I had just said, ‘This is what I think we should do,’ I would have gotten nowhere.”
Sam Lunt, MS, ATC, Associate Director of Sports Medicine at Florida State University, agrees about the importance of spreading the word first. “You have to start in the right places,” he says. “Educate the coaching staff, take the issue to your athletic director or principal, and make sure those people are on your side before you even think about presenting a policy draft to your school board.”
As you gain supporters and momentum for implementing or revising a heat policy, be sure to determine the proper procedure for getting approval. “You have to know the correct protocol for developing policies within your setting,” Almquist says. “You can draft whatever you want, but if you don’t follow the correct procedure, it will not be supported by the right people, and it’s ultimately not going to be followed. You will have done a lot of work for nothing in the end.”
Once you’ve demonstrated the need for a heat illness policy, it’s essential to keep supporters from various groups–such as administrators, coaches, and parents–involved in its creation and maintenance. They will help get the policy adopted, and once it’s in place, ensure that it is followed to a T. The first stop: your athletic department offices.
“You must have your administrators involved in the drafting process because they’ve got the ear of every coach,” Lunt advises. “Coaches may tell you they’re on board, but in reality, once you’re on the field pulling athletes out of drills, they’ll be tempted to fight you. That’s when you need an administrator who can step in and say, ‘Hey coach, we have a policy and this is what it says. The athletic trainer or team physician makes the final decision, not you.'”
Stinson says letting your athletic director and principal have a hand in writing the policy also helps them take ownership of the project. “Ask for their input and explain why certain aspects of the policy are important,” he says. “In the long run, their support will be vital to the policy’s success.”
As the medical advisor for St. Tammany’s committee, Karlin wrote most of the policy himself. “But our administrative members took care of the up-front wording, so they were involved in that way,” he says. “Everyone on the committee read the draft and made corrections and recommendations before we submitted our final proposal to the superintendent.”
The St. Tammany committee met in person five times, and sent e-mails back and forth over the three months the group worked on the project. “It really came together pretty quickly,” Karlin says. “We didn’t try to reinvent the wheel–we pulled from policies already in place in other states and just kind of adapted them to our own environment.
“For instance, some of the policies we looked at used a specific heat index reading to determine when to cancel practice,” Karlin continues. “But our approach is not to stop practices–it’s to alter them so they’re safe. So we have a flag system based on the heat index: Green means we’re good to go, yellow and red mean alterations will be implemented, and we don’t cancel practice until we hit black. Coaches and athletes find a scale much more fair than a straight cutoff.”
Perhaps the toughest group to win over is the coaches. While there are now fewer “old school” types who believe any accommodation for weather is a sign of weakness, coaches face conflicting interests that they can’t ignore.
“Coaches are torn,” says Jeff Hopp, LAT, ATC, Head Athletic Trainer at Marietta (Ga.) High School. “There is pressure on them to win and have a successful program, but hopefully they have their athletes’ best interests at heart, too. In order to have your policy followed, you will need them to understand why it’s there in the first place.”
Karlin found out quickly that coaches were a concern for the St. Tammany group. “I was surprised how worried some committee members were about potential backlash from coaches,” he says. “They thought that making these rules might cause problems. This is SEC country–high school football is big, and any restrictions put on our kids are viewed with suspicion. We really highlighted to the coaches and committee members that we were not trying to prevent practice, but protect practice.”
Educating the sport coaches about the policy–before it was implemented–was at the top of Stinson’s list as he formed his school district’s policy last year. “Coaches can get a little apprehensive when you start messing with their practice times,” he says. “So I told them, ‘These procedures are not designed to make your players less successful. In fact, they’re designed to make them work even more efficiently.'”
The last key group that must take stock in a heat illness policy is the athletes themselves. “We are dealing with very highly motivated individuals,” Lunt says. “It’s not just the coaches doing the pushing. These athletes push themselves past the point where an average person would stop. They’re vying for a spot on the team or a starting position. The players need to know the signs of heat illness and be told to watch out for each other.”
Preseason meetings are a great time to go over the signs and symptoms of heat illness, both orally and through a printed handout athletes can take home with them. Because one athletic trainer and one coach cannot keep an eye on every athlete at every moment, athletes can become your second set of eyes at practices and workouts.
NUTS & BOLTS
So it’s time to sit down and write a policy or update one that hasn’t been revisited in a few years–what should today’s policies look like? While each one will differ due to geographic location and corresponding heat and humidity levels, there are several key areas to address. The first is implementing an acclimatization period at the start of preseason.
“If you look at the epidemiology, football players who die during preseason have all died within the first three days,” Fowkes Godek says. “It never happens during the second week because by day eight, players have expanded their blood and plasma volume by 10 to 12 percent. I have data showing core body temperatures the first, second, and third days versus the eighth to 10th days, and athletes are all significantly cooler that second week.
“The NCAA rules do a great job forcing football athletes to go through a true acclimatization process,” she continues. “The first five days it’s one practice a day and players gradually get into full pads. The first couple of days they’re in shorts and helmets, then half pads or shells, and it’s not until the sixth day they’re in full equipment. Also, there are never consecutive days of two-a-days during preseason. I suggest looking closely at the NCAA’s policy before drafting your own. If you can somehow include early conditioning without full equipment, you can head off many potential problems.”
Deciding what weather will trigger alterations to practices is another important aspect to clearly address. “You can’t simply say that when the temperature is 95 degrees or the humidity is above 80 percent, there will not be practice,” Lunt says. “Coaches and players will have a fit–we’d never practice down here if that were the rule. A policy should be more general. For instance, say you will monitor weather conditions on a daily basis and make appropriate adjustments, not just cancel everything completely. That may mean changing the time practice starts, the type of gear players wear, the intensity of work, or the number and frequency of breaks. On a daily basis, you must communicate with the rest of the athletic training staff and the coaches to make these decisions together.”
Most policies use either a wet bulb reading (which incorporates temperature and humidity) or wet bulb globe reading (which incorporates temperature, humidity, and solar radiation) to determine the risk level of weather conditions.
“But a lot of it is common sense,” Stinson says. “Football coaches, for instance, need to know that when they’re not running a drill in practice, the kids should be encouraged to remove their helmets and must have access to water. Putting something that simple into writing can make a difference. You don’t necessarily have to say there must be formal breaks every X number of minutes.”
One thing both Almquist and Karlin were very cognizant of when drafting their school systems’ policies was to not give any real decision-making power to coaches. “Our policy gives coaches no direct control over enforcement,” Karlin says. “It is specifically written that heat index readings are performed by the school’s athletic trainer or an administrator, and coaches are excluded from this responsibility.”
Your policy should have clear educational material in it–not just a heat index chart and a cutoff point for canceling practice. And it’s your job to make sure the rest of the athletic training staff, coaches, and student-athletes understand all parts of the policy.
“Our athletic training staff sees every coach at every preseason meeting,” Almquist says. “They have the signs and symptoms of heat illness brought to their attention at that time, and we go over the policy so they’re aware we may be telling them they can’t use helmets or full pads on certain days, or maybe can’t even be outside. We inform the kids and their parents at our preseason meetings, and we also have the policy posted on our Web site.”
Karlin and the head athletic trainer at Ochsner traveled around the St. Tammany Parish school district this past spring and summer, holding lectures for coaches and administrators. “They needed to know what the policy is all about,” Karlin says. “Some of them probably didn’t even know we had formed a heat policy. It’s as much an educational tool as anything else.”
The final piece of an effective heat policy involves “what if” scenarios. Outlining the specific steps to be taken when an athlete exhibits signs of heat illness is extremely important.
“An emergency action plan must be part of the policy,” Lunt says. “When is it time to notify EMS? Who is going to make the call? Where are you going to take the athlete in the meantime? Who’s going to direct the ambulance and who will notify the parents? When we created our policy, we made sure those roles were clearly delineated.”
Lunt also thinks proactively, flagging athletes who are at higher risk for heat illness and keeping a close eye on them early in the preseason. “That’s why a good preseason physical is extremely important,” he says. “At Florida State, our physical is extensive, including a full cardiac workup with EKGs so that we’re able to identify at-risk athletes. High body fat, for instance, is an indicator. It’s important that you know the people who tend to have issues with heat.”
Once your policy has been written, approved, and implemented, your work isn’t done. You need to make sure it’s being followed on a daily basis. Educating coaches and athletes is your best bet for enforcing the policy.
“Throughout the first year I was going around to practices to make sure procedures were being followed, and coaches gave me a little grief,” Hopp says. “Our cross country team, for example, practices off campus. When I’d call the coach and say, ‘The wet bulb globe temperature is this high today,’ he’d just tell me he didn’t think it was that hot where they were. So I showed him how to read a wet bulb globe thermometer, which he now takes with him to practice. It was just a matter of making him understand the importance of following the policy.”
Stinson uses a call list to enforce the guidelines effectively. “I have the cell phone numbers of coaches, band directors, and other athletic trainers in our district saved in my phone, and I check in with them whenever I feel it’s necessary,” he says. “I also send e-mail alerts throughout the day, pretty much every day, saying ‘It could get dangerous by practice time, so let’s keep an extra close eye on our players and take more breaks today.'”
Remember that following up isn’t limited to making sure the heat policy is being effectively used by others. You need to follow up with yourself regularly as well, by going back to the policy and tweaking it when necessary. For example, if your existing policy doesn’t address acclimatization, the latest research suggests this is not acceptable. And if your policy stops at outlining the signs and symptoms of heat illness, make sure to add a clear emergency action plan.
“I’ve gone back to our policy multiple times to revise something or add a new detail,” Almquist says. “A policy can almost always be tweaked and improved based on new research and studies. And because the end result is a more effective strategy for keeping our athletes safe, I believe it’s always worth the effort.”
The NATA’s position statement and tips for recognizing, preventing, and treating heat illness can be found by typing “heat illness” into the search window at: www.nata.org.
The American College of Sports Medicine’s consensus statements on heat illness and hydration are available by searching “heat illness” at: www.acsm.org.
The Centers for Disease Control and Prevention has an entire Web site devoted to extreme heat and its effects. A prevention guide, the signs and symptoms of heat illness, and extreme weather tips can be found at: www.bt.cdc.gov/disasters/extremeheat.
The National Center for Catastrophic Sport Injury Research’s most recent Annual Survey of Football Injury Research can be found at: www.unc.edu/depts/nccsi/SurveyofFootballInjuries.htm.
To view the NCAA’s Out-of-Season Football Conditioning Educational Initiatives, go to: www.ncaa.org, select “Publications” from the “Media & Events” menu, and click on “Health & Safety.”
Hydration recommendations to prevent heat illness, administrators’ duties regarding heat illness, and downloadable flyers on heat stress can be found by searching “heat illness” at: www.nfhs.org.