Interview Doug Casa
A leading expert on heatstroke, he is a researcher and professor at the University of Connecticut and chief operating officer at the school's Korey Stringer Institute, named for the Minnesota Vikings' offensive lineman who died of heatstroke in 2001. "There should never, ever be a person [who dies] from exertional heatstroke, because it's 100 percent survivable," he says. This is the edited transcript of an interview conducted on Dec. 17, 2010.
Tell me how you got into this initially.
My interest in heatstroke has existed for about 25 and a half years. I had a heatstroke myself when I was 16 years old competing in a 10K race on the track in Buffalo, [N.Y.,] in 1985. On the final lap I went down, got back up in a couple seconds, and then in about 100 meters I collapsed again, and then I went into a coma for most of the afternoon. I was obviously fortunate to survive that heatstroke, but I developed the passion from that moment, and it's pretty much been my single-minded focus since that took place.
When you say that the Korey Stringer Institute studies sudden death in sports, tell me what sudden death in sports is. What are you tracking?
The Korey Stringer Institute is interested in conditions that could cause an athlete to die, and usually conditions that are often preventable. The common causes of death in sport are things like cardiac conditions, head injuries, heatstroke, exertional sickling, spinal cord injuries. A lot of these injuries, if you have proper preventative policies in place or proper recognition policies in place or proper treatment policies in place, the death can often be avoided. So we are interested in trying to track these deaths or see if there are policies that we can put in place that will either decrease or eliminate the deaths within certain conditions.
... Why now? What's going on now that makes this worth looking at?
The Korey Stringer Institute is interested in these deaths, obviously, just because the kid is losing their life. But it seems recently, within the last five to 10 years, that there's been a dramatic rise in the number of deaths, for various reasons, but heatstroke, sickling, cardiac, head injuries are four good examples that have increased the number of deaths in recent years.
So when you say there's been an increase, why?
There's a lot of reasons why there might be an increase in deaths. You have to look almost condition-specific. A condition like heatstroke and exertional sickling is likely due to the increase in intensity of the conditioning sessions that are taking place. And you're increasing the intensity, the seriousness that's taking place at these practices, but you're not having the proper medical staff there when these emergencies take place. So you have coaches in charge of the emergencies when they take place, and they have no training to properly care for these conditions, nor do they have the proper equipment and ways to assess what condition it is. ...
So, in other words, all of these things seem to have one thing in common, which is that the more serious high school sports get, the more prone kids are to having these sorts of injuries.
Without question, when you raise the intensity and seriousness of the activity, you're going to always increase the likelihood that there's going to be complications associated with it. Now, I have no qualms with making it serious and intense, but parents, beware, because you don't want the coach in charge of the health care for your child. So we can up the ante in terms of the intensity, but make sure you have the proper medical staff there so that if a problem does arise, they're properly taken care of.
Exertional heatstroke can occur whenever a person is physically active, doing either sports, labor, a soldier doing intense activity, usually in the heat but not always, and they do it for a long enough period of time that their body temperature climbs at a faster rate than the body can cool itself.
So, normally, when you do intense activity in the heat, you're probably around 102, 103, but you find an even keel that your body can stay right around that temperature if you keep the same intensity and the temperature outside stays the same. But for some people, the amount of heat that's generated in their body is greater than the heat. ...
Things that put you at risk for that to happen are the intensity of the activity; that's the main thing that drives your body temperature up during activity. But one of the key factors is the humidity that's outside, because one of the key ways you cool yourself is when you sweat, and when that sweat droplet evaporates, the evaporation of that sweat droplet actually removes heat from your body. So when it's really humid outside, that sweat droplet can't evaporate, [and] it just rolls of your skin, you're actually just getting dehydrated, and you're actually not cooling yourself at all. ...
It always seems to be some kind of red herring or some sort of red flag that's out there, whether they're sick that day or there's some more intense activity, because the coach is either punishing them or mad about something, or an athlete wasn't hydrated or didn't sleep well. There's usually some factor that was different for that athlete on that day that might have made them more susceptible.
So the temperature is not necessarily enough to gauge whether that is likely, correct?
The environmental temperature is actually not a strong indicator at all if there's going to be a risk of heatstroke. It's much more important to look at the relative humidity or the moisture that's in the air, something we call the wet bulb temperature. That's a much bigger factor. So when you hear somebody say the heat index, that's better than just using the temperature, because heat index factors in the humidity with the temperature and not just the temperature alone. ...
What would be a scary heat index?
The million-dollar question people always ask in terms of, what is a scary heat index, it all depends on what type of activity you're doing outside. If you're walking outside and you're wearing shorts and a T-shirt, you probably could handle a great range of heat index levels. If you're a soldier in full gear, carrying a pack, a walk might be very difficult.
What if you're a football player?
If you're a football player, once I start hearing numbers that are in the high 80s, you start to make sure you're having modifications during practice: You're having more rest breaks, more hydration; practicing at different times of the day; making sure they're heat-acclimatized, meaning make sure they're used to the heat.
When we get into the 90s, we want to make even more modifications. When it gets up into the 100s, you want to ask yourself, is the benefit of that practice really necessary at that time? And if it is, you just want to make sure you have proper precautions.
I don't usually recommend [that] people cancel practices, but you've got to have proper precautions, and the first precaution is making sure you have an athletic trainer at the practice. If you don't have medical staff there, you really should have much more conservative guidelines in place at your high school, because you don't want the coach caring for the serious circumstances that may unfold.
What about heat index of 116?
If I had a heat index of 116, I'd have to seriously question why I'm having a practice that day, and if I do decide I really do have to have a practice because it's going to be that temperature all week, you really have to make sure there's shade available; you have to make sure there's rest breaks; make sure there's plenty of fluid; you're checking hydration status; your athletes are used to the heat as far as being acclimatized; ... and that you're phasing in the amount and intensity of the practice over the course of days so athletes are getting used to it. There has to be a lot of precautions, but [even with] all of that, I wouldn't have the practice if there wasn't an athletic trainer there, because your risk of danger is exponentially higher with those kind of conditions. You have to at least make sure you're taking care of the kids if there is a problem.
And a heat index of 105? Is that similar?
Anything where you get into the 100s, you're making modifications or changing your practice time.
Why are the numbers with heatstroke are going up?
The incidence of heatstroke in youth, high school, college football, especially high school football, has risen dramatically in the last five years. In fact, the number of deaths is double what the high school average is over the last five years. ...
... There's a lot of reasons. The biggest reason we always point to is it seems that the seriousness and intensity of high school sport has just grown by leaps and bounds in the last five, 10 years -- much greater than what we've seen in the past.
And the kids, while the intensity and the seriousness has increased, they're not prepared for this activity like they've been in the past. You don't have kids laboring outside or working outside. You don't have people having houses that are not air-conditioned so they're used to the heat. So you have kids doing their weight workouts, living and sleeping in air-conditioned environments, and the only time they're actually out in heat is when they're in full gear and doing intense activity in a football practice. So I think they're not ready for that. [Plus] they tend to be larger than they have [been] in the past.
The coaches are much more intense during conditioning sessions. So I think there's a lot of reasons that are coming together. Maybe also the supplements could maybe play a role as well.
Let's talk about the size of players. Do you think that plays a role?
Absolutely. I think the size of an athlete is a big factor in terms of them being more at risk for various conditions, especially exertional heatstroke. So you have these big linemen -- some of them at the high school level could be 250 to 275 pounds -- and if that extra weight is fat, it's doing two things. First of all, it's serving as insulation, which is going to prevent the cooling of the body. Second, you're going to be carrying around more weight during your activity. That's going to make any activity harder. And anything that makes it harder drives up the intensity, and that's going to drive up your body temperature.
So the bigger you are, the more vulnerable you are?
I think if you're carrying more fat [you are], I think, more vulnerable. If you're really muscular and you're 250, I don't think you're necessarily at greater risk than someone who is 250 and who is overweight.
The condition of exertional heatstroke is preventable if you take a lot of precautions. Some of the precautions would be having proper hydration breaks, phasing in and out the intensity of the activity. Something called heat acclimatization is something that's very, very important for high school athletes. Other things like having proper rest breaks and having proper equipment. There's a lot of things you can do to reduce the stress during a football practice session.
But even if a heatstroke does occur -- because you can't prevent all heatstrokes from happening during a football practice, because you might have a kid sick that day; they might be taking a certain medication that you're not aware of. When a heatstroke takes place within organized sport in America, there should never, ever be a person [who dies] from exertional heatstroke, because it's 100 percent survivable ... if you recognize it immediately on-site and you begin aggressive whole-body cooling via cold-water immersion on-site where the heatstroke is actually taking place.
And the reason why that's so important is because you have to minimize the amount of time that the athlete is hypothermic. It basically comes down to 105 and 106 degrees. How many minutes are you above this critical threshold for cell damage will impact whether the athlete lives or dies. So you can't waste time during this cooling process. You have to get them cooled within a few minutes after they collapse so you're minimizing that time. Your goal is to keep it under 30 minutes, the amount of time they're over 105 degrees.
So how critical are the first few minutes after somebody passes out from heatstroke?
The key to surviving an exertional heatstroke is what you do in the first five to 10 minutes. The point is you've got to get them cooling aggressively with whole-body cooling. Cold-water immersion is the best way to cool them, but you've got to get that going within a few minutes after an athlete collapses. ...
Once they're down to 102, 103, that's when you ship them to the hospital. The concept [is] cool first, transport second. You always ship them to the hospital, but you get your aggressive cooling done on-site if there's appropriate medical staff that can handle this on-site. If there's not appropriate medical staff on-site, then you would immediately have them transported to the hospital.
Why are these first few minutes so crucial?
The first few minutes are critical because your body can only handle a certain amount of time that it's in this hypothermic zone. So we think it's probably close to 105, 106 degrees that your body can only handle 30 to 45 minutes above that temperature, so you can't waste any time in terms of transport, waiting for other things, waiting for care.
We always recommend having a tub half filled with water and having coolers right nearby filled with ice so that you can have a cold tub available within a few minutes. That should be available at high school football practices, especially during August, in our country, where the risk of heatstroke is highest.
Let's go back to the importance of athletic trainers. If you could, tell me what the state of affairs is in terms of athletic trainers in this country and why that's such a problem.
Sure. The key to preventing sudden death in sport at the high school level in our country is having an athletic trainer on-site when an injury takes place. Currently ... only about 40 percent of high schools in America have athletic trainers on-site on a regular basis, and that's going to be a key factor, because parents don't want fellow athletes or coaches or parents providing health care for their child.
There's a lot of reasons why an athlete can be unconscious, on the brink of death on the practice field, and a medical professional is going to make that assessment on what the condition is: Is it a head injury? Is it heatstroke? Is it sickling? And the assessment needs to take place because the treatment is all very different in these causes of sudden death in sport.
So how concerned are you, is your institute, with these issues?
The Korey Stringer Institute, one of the main goals that we have is to have an athletic trainer at every high school in America. We're big believers that if you're going to have an athletic department in your high school, you should hire your athletic director first and your athletic trainer second, and then you should worry about worrying about your coaching staff. And we wish that parents and administrators would feel the same way, that health and safety always should trump success and performance on the playing field. Success and performance -- we care a lot about that, but we want to make sure health and safety is first prioritized.
Is that most people's priority?
Absolutely not at this point, unfortunately. I mean, you can just look at the data. Most high schools don't have athletic trainers, and even the schools that do have athletic trainers only have them part-time and are only available for just a couple hours each afternoon. ...
Now, in terms of the importance of having an athletic trainer available at all times and not just at games, can you explain why that's important?
It's extremely important for people to understand that it's more important to have an athletic trainer at practices than at games. A football player or any athlete at the high school level is much more likely to die on a practice field than they are at a game, and the reason for that is -- and I'll give football as an example -- is that in football games, people have breaks, and there are recovery periods. So when it comes to heatstroke or exertional sickling, those conditions are just not likely during games, but they are very likely during practice sessions, where a coach could have very rigorous conditioning and practice regimens, and it could place them at greater risk. So we want to make sure athletic trainers are available at the high-risk sports during practices as well as during games.
How many states have policies in place about this? Are there national guidelines about this? We're talking now about heatstroke, specifically football-related.
When it comes to guidelines for high school football in America, currently only about half the states have guidelines that focus on heat acclimatization. And just to explain what heat acclimatization is, that's the phasing in of practices during the first seven to 10 days. When I say "phasing in," I mean increasing the amount of physical exertion each day, the amount of equipment you have on, increasing the intensity of the activity.
Over the course of those seven to 10 days, your body goes through some very powerful physiological changes, and you get better and better at handling that exercise in the heat. So if a state does not have good policies, and they do, for instance, three-hour practices on the first day, you're jeopardizing these kids' health, because some of these kids are not going to handle the heat that well on that first day, whereas a week later they'll all be better off if you've phased in the amount of activity and the intensity of that activity. So it's absolutely critical, but only half the states have policies like that. ...
In fact, in June 2009, the National Athletic Trainers' Association [NATA] released national guidelines for high school heat acclimatization so that states, superintendents, principals would have guidelines to follow for the phasing in of practices in August. We're working diligently now to try to have each of the states to approve these guidelines, but we have a long, long road ahead and a lot of roadblocks.
What are the roadblocks?
The roadblocks [are] you don't have a lot of great leadership from the national governing body. Having to do with the high school federations, they were initially on that document and pulled out a few weeks before we released that document because they were very scared that some of the states and coaches might not be in support because they'd have to change what they had done for a long time.
But we believe change would be good, because change is just focused on the health and safety and well-being of the athlete and in no way jeopardizes the quality of football that they could have on the playing field. We even recommend that if someone has to start a week earlier in order to get all the acclimatization in and still have all the practices they would already have, [that's what they should do]. We in no way want to jeopardize performance, but health and safety comes first, and unfortunately we aren't getting great leadership at the national level. Some states have been very proactive and have some good guidelines, but we have a long way to go. ...
Isn't it just a better idea not to practice in the heat?
... I'm for guidelines that as it gets hotter, you have more modifications and you have more strategies. You have more work-to-rest ratios, so you have more rest breaks with different heat indexes.
Now, certainly there are some heat indexes that scare me, especially in the first week, when an athlete is not ready. So I always focus on heat acclimatization. There are also states that have policies, based on just the flat-out heat index, are we going to practice or not? ...
Who polices this sport? Where are the police?
The policing of high school football in America really happens at the state level, because the National Federation [of State High School Associations] that sets some of the policies doesn't really have any teeth to invoke specific rules that the state has to follow. It's not like college or pro where there's a national governing body that the people have to follow the rules. ...
So why haven't they taken more of a stand?
My perspective with the national federation is that they just haven't been gutsy enough with standing up to the coaches. And federations, they don't want to bother people who have been set in their ways for a long time. I think they need to get more aggressive with their policies. ...
What about at the state level? How many policies are there?
At the state level, specific to heat acclimatization, about half the states have policies that we are comfortable with, in terms of the guidelines we released in June 2009. ...
What do you think the reasons are that states aren't adopting these? I mean, they're not difficult to adopt.
I think from the medical perspective, most states would be completely onboard. It's just if you follow the policies, it's very different from what most people are doing with high school football that first week of practice. So, obviously, if there's something that's a massive change, it's going to cause a massive amount of controversy, so some states have just pushed forward and don't really care that some coaches do not agree with the policies. Others have met a lot of resistance, but eventually we'll have all 50 states that have good policies. But like anything, it will just take a lot of work and, unfortunately, a lot of kids to die along the way. ...
The issue of long-term damage -- I am going to ask you about a specific incidence. The [Will] James boy, who was in a medically induced coma for at least a week and was then on dialysis for at least three weeks when he was released from the hospital -- he was in the hospital three weeks and then at home on dialysis for three weeks, and he did return to football practice and ultimately to football games within [a month].
When an athlete suffers exertional heatstroke, and they're cooled aggressively and recovery promptly, which means they recover fine and they're home the next day and there's no long-term complications, even an athlete in that situation is going to be out of activity, we recommend, at least in the four-to-eight-week range.
Any athlete who has complications with the heatstroke, meaning they're hospitalized beyond that first day of the heatstroke, is going to fall into a different category, and those athletes are going to be out at least three to six months from the resolution of signs and symptoms, because there's a lot of recovery that takes place.
When you come back from a heatstroke, there's a lot of things one has to consider. The U.S. military, specifically the U.S. Army, this past summer released new guidelines on how they're letting their soldiers come back to activity following heatstroke.
And if you use that as just a working model, there's a lot of factors to consider. One is what caused the heatstroke in the first place, so you might need some time to correct that factor if it's inherent to the person; for instance, their conditioning and other factors. Second, what complications happened in the body after the heatstroke took place, whether within the brain, within vital organs, within the muscle. That takes a long time to recover. Also, their heat tolerance. A lot of people who have heatstroke have a compromised exercise-heat tolerance for some time period after the heatstroke takes place, so if you put them back out in the heat, they might not even be able to do as well as before they had the heatstroke. And third, you're putting them out there with their teammates, who are now in better shape and better acclimatized than this teammate who had the heatstroke and is going back. So they have to make sure they work back up to the fitness level of their teammates, not from back when they had the heatstroke in the first place.
So there's a lot of factors to consider. It's a long process. It should be considered like any other illness or injury when you're working to rehab someone back from heatstroke. But it's very safe to assume someone who is treated properly and recovers quickly is going to be out for at least a month, and someone who has some long-term complications is going to be out at least three to six months and maybe longer.
So, going back to football practice within a few weeks from [being] released from the hospital is not possible.
I would absolutely not. Well, if someone's released from the hospital following a heatstroke, and they went to the hospital just as a precaution, and they're just there for just one night, and they're totally fine, and the tests come back good, I would be potentially comfortable with that person being back to practice within maybe a month later. But anybody who has had any complications and is getting care at the hospital because of organ damage or because of things that took place, you're looking at least a three-to-six-month window before they go back to activity. We would allow somebody to walk or jog or work their way up. ...
Why don't more schools have athletic trainers or medical personnel on-site?
The common reason that is often cited as to why they don't have an athletic trainer at the high school level often goes back to financial reasons. That's the reason you hear from the superintendent or the principal or the athletic department, that they just don't have the budget to pay for an athletic trainer to be on-site.
Our response for that is that they always find money for the equipment and the coaches and all the fields and the upkeep of the fields, and to pay all the people [involved in] running a high school sports program that has 500, up to 1,000 athletes, but yet they can't hire one person that's going to be in charge of the health and safety of these players and is going to have all the right policies in place, all the right procedures in place for when a problem does occur and try to prevent a lot of problems from occurring in the first place?
It's not just the poor, destitute, tiny little schools that don't have trainers?
Very good point, that it's a wide range of schools in America that don't have athletic trainers. It's not just the poor schools or the smaller schools. Even poor and smaller schools can work out plans with local medical facilities and can still have access to local medical trainers where the cost doesn't have to be exorbitant.
But any kind of midrange to larger high schools in America really should have athletic trainers on-site, full-time, employed by the high school, so they can do some rehab during the day and they are available all throughout the afternoon practices and are available at events in the evening.
Would you describe this as a crisis?
There's no question from the perspective of the Korey Stringer Institute that the concept of sudden death in sport is at a crisis level right now in terms of the number of deaths that has been occurring, and the key thing is the number of preventable deaths that are occurring. So these parents and these teammates and these coaches have to live with the fact that this athlete could have easily survived, either if they'd done some easy precaution to prevent it from happening in the first place or had the proper care implemented in the first 15 to 30 minutes after the condition took place.
Why do you think parents allow coaches to be responsible for the health and well-being of their children?
The culture in our country is that when a parent drops their kid off at their practice, they are comfortable with the coach being their guardian at that time. And I'm generally comfortable with how that takes place, but not when it comes to medical conditions that need to be taken care of during the practice, because the coach has no training beyond basic first aid in terms of how to prevent, recognize and treat the myriad of conditions that can cause sudden death in sport. And even if you look beyond sudden death in sport, [look at] serious orthopedic injuries and other potential problems on the athletic field, the coach is just not the person who is well trained.
When I talk with parents, I always tell them to beware when you leave your kid at a practice field. What's happening there? Is the coach really looking out for the best interest of their health and safety, or is their primary focus winning their next game? ...
Now, looking at sudden death in sports, what is the proportion of those that are football-related? And why is football such a high percentage?
In terms of sudden death in sport, especially at the high school level in our country, the sports that have the greatest risk are track/cross-country and football. Football seems to be the one that has the greatest death, and probably about two-thirds to three-quarters of the deaths we see related to sudden death at high schools in America are related to football.
Why is football the one that has the greatest risk? I think there's a few factors that come into play. One is they're doing their most intense activity during the hottest time in America. So heat might be more likely to cause heatstroke, but it also might put them at greater risk for other conditions as well. Second, they're wearing a lot of equipment, which you don't see in a lot of the common high school sports in America, so that increases the risk. Third, the sheer number of people playing football is greater than other sports in America. In terms of participation, it's the number one sport. Then also the size of the athletes. There's no other sport where you get 250-to-300-pound athletes asked to do very intense activity for two to three hours in 100 degrees, wearing a lot of equipment. ...
Now, last year there were two very serious heatstroke cases in Arkansas minimally, and two in Oklahoma. Why those two states?
I don't think there's anything specific to Arkansas and Oklahoma as to why they had the heatstroke deaths this past year. ... We've seen a lot of cases in Kentucky over the last few years. I think it just is a revolving door in terms of what state. The states that don't have the great policies in place [and] the states that don't have athletic trainers at the high school are the ones that are much more likely to have problems. ...
[Are there heatstroke policies at the college level?]
One of the largest sports organizations in our country, the NCAA [National Collegiate Athletic Association], that oversees college sports in America, in 2003 developed a great set of guidelines to protect athletes who are exercising in the heat in August. It's specifically geared toward football players. And they have this heat-acclimatization policy where, as an example, on the first five days you can't do two-a-day practices. And then starting on day six you can do two-a-days, but not on successive days. So days six, eight and 10 you could do two-a-days.
Also, it phases in the equipment, so you might just be in minimal equipment for the first two, three days and then a little more equipment, then maybe in full gear when it's close to a week.
So all of these things just gradually increase the stress that the athlete is under in that first seven to 10 days. And this model that the NCAA developed in 2003 has clearly shown it's successful, because in that seven-year span, as far as we know, there's only been one death we know of during those August practices during this phase in time of activity. So this is our model in terms of what we [did] in 2009 when we released the high school guidelines, and we want to see similar things adapted by the 50 states in our country. …