By Janet Lewis, ESQ.
The National Centers for Environmental Information (NCEI) announced recently that July 2015 was the warmest month ever recorded across the globe. Additionally, the period of January-July 2015 was recorded as the warmest January – July since data started being collected in 1880, and 9 out of 10 of the hottest months on record have happened since 2005. In other words, it is hot.
As training camps and pre-season workouts begin for high school and youth level fall sports, heat will play a role throughout nearly every practice. Fortunately, the dangers of heat-related injury are understood by many. When it comes to heat-related injuries, most will often think of football (and they do have the highest incident of heat related issues due to higher body mass index, the wearing of pads, the physical nature of the game and the fact that their sport is often played in the heat without shade). However, all outdoor sports need to proceed with caution. For example, running races, field hockey and soccer games are often held in the summer and fall months when it is very hot. In fact, at the Falmouth road race, a seven-miler held in mid-August each year, “At least one runner in every 1,000 entrants … suffers a potentially deadly exertional heat stroke…an incident rate 10 times higher than that reported at cooler races in the spring and fall.” Since 1984, more than 270 cases of exertional heat stroke have been reported at this race alone.[4]
So the question for high schools, and even youth sports, is how do you not only protect your athletes from suffering potentially deadly injuries, but also protect your school, staff, coaches and others should someone get hurt?
Knowing the Problem
There are several ways heat can affect athletes, much of it attributable to dehydration and overexertion. Dehydration is affected by the intensity of exercise, temperature, humidity and how much fluid is restored during exercise. Increasing levels of dehydration cause both body temperature and heart rate to rise, which will increase the risk for heat illness. “Once an individual loses 2% of their body mass from fluid losses impairments in performance are noticeable and these impairments become more extreme with great levels of dehydration.” [5] This can lead to Exertional Heat Stroke (EHS). EHS is among the top three reasons athletes die during sport and is characterized by a body temperature greater than 104 degrees Fahrenheit, as well as headaches, confusion, altered states of consciousness, vomiting and/or collapse.[6]
Injuries in sport are expected. High school athletes suffer two million injuries, 500,000 doctor visits and 30,000 hospitalizations each year. There were 120 sports-related deaths of young athletes from 2008-2011. Yet only 42% of high schools have access to athletic trainers.[7] Many of these injuries are “freak injuries” or ones that may not have been preventable. Heat-related injuries, on the other hand, can be prevented. The majority of EHS cases occur during initial summer workouts when athletes are neither prepared to cope with the heat nor with the new demands that they place on their bodies during their workouts.[8]
High school athletes, especially males, are at the highest risk of suffering exertional heat illness requiring treatment in the ER. According to the National Center for Catastrophic Sport Injury Research (NCCSIR), since 1995, 54 football players died from heat stroke, 42 of which were high school athletes and 90% were in practice. There were 13 deaths from 2010-2014 alone.[9] From 1996-2006, the number of heat-related injuries rose 33% and youths accounted for 47.8% of those injuries.[10]
Making Headlines
Following the highly publicized death of NFL player Kory Stringer in 2001, heat-related injuries were thrust into the spotlight. The NCAA adopted heat acclimatization guidelines in 2003 and the NFL followed with comprehensive plans in 2011. However, only 13 states have guidelines or laws for high schools[11] and there are generally no guidelines for youth sports. While the NFL and college players generally can be assured that they have athletic trainers, immersion tubs and best-practices in place that take into account modern heat stroke research, high school players may attend a school that doesn’t even have an athletic trainer.[12]
Florida and Georgia have enacted fines of up to $5,000 for non-compliance and/or post-season bans. Maryland has laws, but no means of enforcing it. “By not mandating heat acclimatization guidelines, states are failing to protect their athletes and, in fact, are placing them at greater risk for exertional heat stroke and other heat related illnesses.”[13]
A first important step to preventing dehydration and heat illnesses is education of all staff, coaches, trainers, athletes and parents. “All personnel involved with the organization of athletic activities share a professional and legal responsibility to ensure that guidelines are in place to manage any emergency that could arise.”[14] Everyone should be aware of how to assess hydration and how much fluid one needs to replace during and following exercise (methods include calculating sweat rate and reviewing urine color). In addition, coaches can use a Wet Bulb Globe Temperature (WBGT) to determine if it is even safe to be outside for physical activity and/or if modifications should be made for the upcoming workout. All athletes, coaches, trainers and parents should know and understand the signs and symptoms of heat related illness.[15]
In addition, all programs should adopt a heat acclimatization policy that outlines the steps that should be taken to ensure safely ramping up workout intensity and frequency over a 7-14 day period. This would include no two-a-day practices for the first five days, and following two-a-days with a single practice the next day. The Korey Stringer Institute also recommends each practice be three hours or less, increasing sodium in diets and taking frequent rest/water breaks with a hydration kit on hand (see ksi.uconn.edu/prevention/hydration). This allows the heart rate, body temperature responses and perceived exertion to be lowered while increasing sweat rate, sweat onset, heart function and overall ability to perform in the heat (for a full list of tips see ksi.uconn.edu/prevention/heat-acclimatization).[16]
Perhaps the most important element to ensuring preparedness and limiting liability is the creation and implementation of an EMERGENCY ACTION PLAN (EAP). An EAP provides information to ensure that response to an emergency is rapid, appropriate, controlled and precise.[17] This document should be comprehensive, yet flexible and updated and reviewed annually with all coaches, staff and athletes. In addition, there needs to be commitment to training and rehearsal of these plans. While a coach should never be the primary medical provider, education about emergency care and methods are vital. All coaches should be trained in CPR/First Aid and AED certified — and renewed regularly. They should also participate in EAP training and if in high school, be National Federation of High School Association (NFHS) certified.
Plan Ahead
Having a plan in place with resources available immediately is essential. This includes trainers but also water, cooling stations and cooling tubs. In fact, submerging a heat stroke victim in a cooling tub can immediately start lowering the core body temperature. (Dr. Douglas) Casa’s research reports a “100 percent survival rate in cases where the core body temperature was cooled to below 105.5 degrees in the first half hour.”[18]
Response times are critical and a well-documented and rehearsed EAP can reduce response times. For example, each minute that AED administration is delayed, the athlete’s chance of survival decreases by 10%.[19] EAPs should therefore, be specific to the sport and venue, address personnel to assist and establish lines of communication. It should outline available equipment, emergency transportation plans, venue directions and roles of first responders.
Without an EAP, there’s a risk to the athlete and all others involved in the sport. While public schools liability is limited, coaches can still be held liable through claims of negligence, citing an owed duty of care, a breach of that duty and that the breached duty caused an athlete to suffer measurable injury. Without an EAP, the school and coach didn’t remedy an unsafe condition.[20] Attorney Ben Crump represents two football players who died in 2011 and has claimed that the school “negligently hired, trained and supervised and failed to use proper policies or procedures to address heat-related illness.”
The benefits of an EAP are vast. Not only can they lead to the prevention of athletic injury and provide a more effective emergency response, but they insure a program is readily prepared for emergency situations. It ensures that appropriate care is available in a timely manner and will limit legal action, protecting the liability of schools, coaches and administrators.
The best defense will always be proactive offense. Prevent civil and criminal liability by exercising reasonable care for safety under hot and humid conditions. Instruct athletes on safe procedures and warm them of the risks and dangers so that they, too, can recognize signs of heat injury. By providing medical assistance and creating and following an EAP, the liability for those involved can be greatly reduced, along with the injuries themselves.
Ms. Lewis is the Director of Sports & Athlete Relations with Philadelphia-based Locks Law Firm. She can be reached at 215-893-0100 or jlewis@lockslaw.com.
[4] Poitras, Colin. “Keeping Runners Safe in Summer Heat.” UConn Today. Web. 13 Aug. 2015.
[5] Coaching Education. Korey Stringer Institute. http://ksi.uconn.edu/prevention/coaching-education/. Web. 13 Aug. 2015.
[6] Poitras, Colin. “Keeping Runners Safe in Summer Heat.” UConn Today. Web. 13 Aug. 2015.
[7] Southwest Athletic Trainer’s Association. http://www.swata.org/statistics. Web. 13 Aug. 2015.
[8] Heat Acclimatization Policies. Korey Stringer Institute. http://ksi.uconn.edu/high-school-state-policies/heat-acclimatization-policies/. Web. 13 Aug. 2015.
[9] Tanier, Mike. “Korey Stringer’s Sacrifice and the Battle to Stop Football Heat Stroke Deaths.” Bleacher Report (Aug. 3, 2015). Web. 13 Aug. 2015
[10] Southwest Athletic Trainer’s Association. http://www.swata.org/statistics. Web. 13 Aug. 2015.
[11] Heat Acclimatization Policies. Korey Stringer Institute. http://ksi.uconn.edu/high-school-state-policies/heat-acclimatization-policies/. Web. 13 Aug. 2015.
[12] Tanier, Mike. “Korey Stringer’s Sacrifice and the Battle to Stop Football Heat Stroke Deaths.” Bleacher Report (Aug. 3, 2015). Web. 13 Aug. 2015
[13] Heat Acclimatization Policies. Korey Stringer Institute. http://ksi.uconn.edu/high-school-state-policies/heat-acclimatization-policies/. Web. 13 Aug. 2015.
[14]Emergency Action Plans. Korey Stringer Institute. http://ksi.uconn.edu/prevention/emergency-action-plans/. Web. 13 Aug. 2015.
[15] “Heat Illness among High School Athletes — United States, 2005-2009.” Centers for Disease Control and Prevention. Web. 13 Aug. 2015.
[16] Heat Acclimation. Korey Stringer Institute. http://ksi.uconn.edu/prevention/heat-acclimatization/. Web. 13 Aug. 2015.
[17] Emergency Action Plans. Korey Stringer Institute. http://ksi.uconn.edu/prevention/emergency-action-plans/. Web. 13 Aug. 2015.
[18] Tanier, Mike. “Korey Stringer’s Sacrifice and the Battle to Stop Football Heat Stroke Deaths.” Bleacher Report (Aug. 3, 2015). Web. 13 Aug. 2015
[19] AED Policies. Korey Stringer Institute. http://ksi.uconn.edu/high-school-state-policies/aed-policies/. Web. 13 Aug. 2015.
[20] LaMance, Ken. “Liability of Public Schools for Injuries to Players in School Athletic Events.” Legal Match (20 Aug. 2014). Web. 13 Aug. 2015.
