The Risk of Exertional Heatstroke to Young Athletes

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Growing up as an athlete in Louisiana, I was one of many teenagers who took to the football field for summer two-a-day practices. In the nearly tropical summer heat and humidity, we would practice and play in triple-digit temperatures – almost always in full padding. Between sessions, my teammates and I sometimes stood under cold showers for 15 minutes, wearing our full uniforms, just to try to cool ourselves down. It was in those temperatures that a player I knew collapsed and died on the field from exertional heatstroke, or EHS.

EHS is a severe form of heat-related illness and a medical emergency that can result in brain and other organ damage, or even death in some cases. According to a 2015 article in The Journal of Applied Physiology, EHS ranks as the third leading cause of sudden death in high school athletes.

EHS can occur in otherwise healthy individuals and is different from classic heatstroke, which usually affects those who are very young, elderly or have pre-existing medical conditions. Athletes and soldiers whose uniforms require heavy gear are especially vulnerable.

Treatment for EHS has evolved very little over the centuries, essentially relying on external cooling methods. Water immersion, an earlier version of cold water immersion (today’s first line treatment for EHS), was described by the Greek physician Hippocrates in 400 B.C. But even as today’s young athletes and their parents are becoming better informed about the risks of concussion and dehydration out on the field, many believe that heat is merely uncomfortable and do not recognize the dire risks it can present.

Some of this risk could be reduced if high school athletic organizations followed the lead of professional and college teams in banning two-a-day summer practices, which unnecessarily subject young athletes to the risk of exertional heatstroke.

In April, the National Collegiate Athletic Association banned two-a-day summer practices for Division I college football players, on the basis of recommendations from medical professionals, coaches and administrators. The change is intended not only to control exertion on the field and promote recovery from it, but also to minimize injuries such as concussion and lower the risk of EHS.

The National Football League banned two-a-day practices six years ago, in 2011. But many high school football players still face the risks associated with two-a-day practices. Currently, guidelines vary across state lines. While states like Iowa have banned two-a-day practices, others like Georgia and Texas ban only back-to-back two-a-day sessions and other states still allow them.

I’ve served as a physician, researcher and consultant for more than 20 years in an effort to bring wide attention to the issues and threat of concussions in football. And now I have ample grounds to believe that EHS qualifies as an issue of similar importance. While many people think of EHS as a temperature issue, it’s truly a neurological and metabolic emergency that, if not treated, can result in irreversible damage to the brain, other vital organs, or even death. According to research published in the American Journal of Preventive Medicine, the number of injuries associated with exertional heat illness in the United States – most of which involved young people playing sports – increased by more than 130 percent between 1997 and 2006.

It is vital for EHS to be identified as early as possible, so that the person can be removed from the hot and humid environment and be treated. EHS occurs when the core body temperature rises to dangerous levels – 104 degrees Fahrenheit or greater. Such a high core body temperature, even for a short period of time, can cause permanent damage to the brain, liver, kidneys and other organs.

It’s particularly ominous when the central nervous system becomes involved; there is the potential for progression to coma and death. For those who survive, long-term and potentially irreversible neurological damage can occur, affecting cognition, movement, coordination and sensory systems. I’ve personally seen how such nervous system deficits can devastate patients, impairing everything from performing basic tasks to engaging in social interactions with friends. These effects often strike young, active patients who are in the prime of their lives. And because the effects of heat are cumulative, people who have had other heat stress experiences are more likely to experience heat illnesses – like EHS – again, and should take particular caution when exerting themselves in hot or humid conditions.

As a physician dedicated to the practice of sports medicine and as a former athlete, I’m committed to raising awareness of EHS and ensuring that parents, coaches, athletic trainers and others are prepared to recognize EHS and respond.

The Korey Stringer Institute, named for the Minnesota Vikings player who died of exertional heatstroke in 2001 at age 27, offers useful guidance on its website. In addition to a high core body temperature, the signs and symptoms of exertional heatstroke include fainting or dizziness, vomiting, confusion and disorientation and unusual behavior like aggression. Exertional heatstroke is a medical emergency, and fast treatment is critical.

If you see anyone exhibiting the signs and symptoms of EHS, call 911 immediately and initiate rapid cooling, ideally with an ice bath. It’s important to remember that seemingly healthy people can be at risk.

If organizations that represent high school athletes consider adopting the N.C.A.A.’s complete ban on two-a-day practices, they may help prevent fatalities like that of the player I knew years ago in Louisiana.