Exertional Heat-Stroke Preparedness in High School Football by Region and State Mandate Presence
Kerr ZY, Scarneo-Miller SE, Yeargin SW, Grundstein AJ, Casa DJ, Pryor RR, & Register-Mihalik JK. Exertional Heat-Stroke Preparedness in High School Football by Region and State Mandate Presence. J Athl Train. 2019 54(9) Online ahead of print September 2019. doi:10.4085/1062-6050-581-18.
Take-Home Message
Overall, 7 out of 10 football programs are not implementing six key heat-stroke preparedness strategies. Football programs within warmer regions of the United States and/or with state-level mandates had better compliance with these strategies than those without mandates or within other areas of the country.
Summary
Exertional heat stroke is a leading cause of death among athletes. Many guidelines and recommendations promote preparedness strategies for exertional heat stroke to reduce the risk of sudden death. Unfortunately, compliance with these guidelines varies. These authors examined if compliance with exertional heat stroke preparedness strategies among high school football programs was related to heat safety regions or state preseason heat-acclimation mandates. A total of 910 high school football athletic trainers (ATs) responded to a survey (13% completion rate). Responding ATs reported their high school’s exertional heat stroke preparedness strategies for the 2017 preseason. The authors inquired about 6 strategies: 1) education for recognition and treatment of exertional heatstroke, 2) policy for initiating medical services, 3) emergency response plan for school athletics, 4) immersion tub filled with ice before the start of practice, 5) monitoring wet-bulb globe temperature (WBGT), and 6) hydration access. The authors considered 3 heat safety regions based on WBGTs during warm seasons. For example, the mild region included New England and the hot region included the southeastern region of the United States.
A total of 28% of the ATs responded that their high school used all 6 preparedness strategies. Almost all ATs reported ensuring hydration access (99%). The least common strategy was monitoring WBGT (53%). The hottest region reported the highest use of all 6 strategies (34%), followed by the moderate region (25%), and mild region (19%). About 35% of ATs within states that had heat mandates reported using all 6 strategies compared to 26% of ATs in states without mandates.
Viewpoints
This study is interesting because the authors found that 7 out of 10 ATs are not implementing all six preparedness strategies recommended by the National Athletic Training Association Inter-Association Task Force. The actual number may be higher since over 85% of contacted ATs failed to complete the survey. It’s particularly concerning that so few football programs in the moderate and mild regions adhere to the recommendations because 25% of the fatalities happen in these cooler regions. It would be interesting to see if these fatalities were from football or from other sports. Regardless, we need to do a better job implementing exertional heat stroke preparedness strategies. Unfortunately, state mandates may not be enough since only 35% of programs used all 6 strategies in the 8 states that mandated the preparedness strategies. The question remains what the mandate is and whether people are not complying or implementing alternative strategies that they believe meet the mandate. Ultimately, these findings provide evidence that exertional heat stroke preparedness strategies and compliance is improving, but we need to continue to make improvements across all regions, and possibly start to look at all sports (not just football).
Questions for Discussion
What is your current practice regarding cold water immersion preparedness at your site? What do you think some barriers are for these guidelines being implemented in all high schools?
Written by: Daniel Webb & Nicole M. Cattano
Reviewed by: Jeffrey Driban
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I think this is post is very interesting. As a masters student I am doing my masters thesis on hydration during preseason football practices. Through my own data collection I have found that there is not a ton of education to the coaches and players regarding hydration. Additionally, I find it very shocking, yet believable that only 7 out of 10 ATs are not implementing all six preparedness strategies recommended by the National Athletic Training Association Inter-Association Task Force. In my opinion, I feel as though a lot have the mindset that it won’t happen to them, especially those in the cooler states. When we know this may not be the case. I think that continued education to ATs, coaches and even athletes will help make improvements in Exertional heat stroke preparedness strategies.
It is quite alarming only a small number ATs are implementing and following all six of the preparedness strategies. I think the results would have been higher if the authors have re-worded a few or their survey questions. The authors definition of immersion tub could have been to strict, which they acknowledge as a limitation or ATs monitor the weather but not WBGT. A follow-up survey is definitely warranted to see if there is an increase the usage of all six preparedness strategies.
I do agree with you that coach, ATs and parent education is important to make sure all high schools are prepared for heat stroke.
Personally was shocked by the low percentage of AT’s that performed all 6 preparedness strategies even though there were in state with mandates (35%). Knowing that even with state mandates we are not following strategies in place to prevent heat illness cases I’m not sure what could change this matter. It’s not like the news stories don’t come around with the start of football preseason camps, people just don’t think of heat illnesses will happen to them especially in cooler states. Just continuing education with coaches and parents may provide some sort of increase especially if performed with coaches every year so they don’t become complacent and halt assistance with performing these strategies. Interested to hear any ideas on how to combat this problem.
Unfortunately, those news stories are main driving force for change, especially in a low budget high school were they might not be able to afford a cooling tub. So the ATs turn to cheaper options like ice bags and fans. I agree with you, that there should be education with coaches and even the athletic director every year to inform them that exertional heat stroke can happen. Even in the cooler states and to follow these guidelines to protect the student athletes.
If in a low budget high school talking to the AD about being prepared for heat stoke in the warmer pre-season months is key for athlete protection. Starting a fundraiser with the goal to purchase a immersion tub or wet-bulb thermometer. Maybe turning to the booster club for assistance. Then maybe there will be an increase in the usage of all six preparedness strategies.
Overall, I think this is a very important article. It definitely brings awareness when it comes to heat illnesses. Having these strategies helps implement better action plans and will most certainly decrease the number of casualties.
As second professional phase level student the first thing my perceptions went over with me during pre-season was their EAP for everything, which I am now required to know. Being that it’s a high school serious matters are taking when it comes to the health of these athletes. It was asked of me to read the NATA position statement regarding heat illnesses while I was at pre-season. I have seen and helped implement all 6 preparedness strategies recommended by the NATA Inter-association Task Force when dealing with heat illnesses.
What I think is most important is knowing the signs and symptoms. Sometimes you may not see it but you must recognize it. To me if an athlete is sweating profusely, I think action should be taken almost immediately.
I have to agree with Breana here, ATs may think because they are in a cooler environment the chances of the athletes having heat illnesses are low. While this may not necessarily be true, I still think there should be some type of action plan just in case. Heat illnesses don’t only occur because of warmer weather. It has a higher rate of happening in a warmer environment, however, as ATs we should be prepared at all times for anything.
I also believe coaches can be one of many barriers stopping these strategies from taking place. Coaches are hard to deal with. Coaches, parents, staff etc.. should be educated in this just as much as us health professionals. This should help the number increase.
7 out of 10 ATs are not implementing all six preparedness strategies recommended by the National Athletic Training Association is a very low number and I did not ever expect it to be this low. ATs are always busy, they do everything. It is possible that may be another reason why the surveys were not completed.
I agree with you Daminska. Knowing the signs and symptoms for heat stoke is key. When in doubt cool them down in a cooling station. This article does not mention this but it is important to monitor core temperature in an athlete for safe transport when EMS does arrive on site. The AT dealing with the athlete suffering from heat stoke needs to know this athlete is properly cooled down to a safe level.
It also needs to be put into consideration where the athlete just moved from. This is more common in college but if a high school athlete just moved from a northern state (Maine) and moved to a more southern state (Alabama) they would need a longer acclimatization period. ATs with new athletes should recognize athletes that may need a longer acclimation because they have moved to a new warmer state. Talking to coaches about these athletes may help prevent against heat stoke in some populations.
7 out of 10 ATs are not implementing the preparedness strategies in high school football. Do you think this number would rise if this survey was given to all high school sports and colleges?
My apologies, Brittany
I believe this article is definitely alarming. When states that have mandates to follow but still do not implement all 6 preparedness strategies is crazy. In my experience as an ATS in Michigan, I haven’t seen all 6 strategies in the 3 clinical rotations I’ve had in high schools. Maybe this is because we are a more northern state in the U.S. and our temperatures don’t reach as high. However, the WBGT can certainly increase with the amount of humidity we typically have in the summers. This mindset of it won’t happen to me can definitely take into effect when you practice in a state that is consider a cool state and not an at risk state. Another barrier could be the fact that we don’t have 100% coverage in all high schools. Some schools don’t even have the AT’s who have the knowledge in the severity of heat illness and how crucial it is to act quickly. I have this constant belief in mind whenever I see reported athlete deaths: How many kids are we going to allow to die when education and preparation could easily be a solution? 7 out of 10 AT’s are not implementing all six preparedness strategies recommended by the National Athletic Training Association Inter-Association Task Force, that number is WAY too high. This “it won’t happen to me” mindset has got to go.
After thoroughly reading this article, it was quite shocking as to why some ATs aren’t following these strategies and even taking the surveys. In all honesty, some ATs will put something so important like this behind them and to think that something as crucial as this won’t even happen. Being at the clinical site I am at; my preceptor and I haven’t gone over as to what their preparedness is in regard to cold water immersion. Even though I am at PT clinic and there aren’t any athletes that come in, I still work with an outside football team where they are closely monitored when it comes to any heat strokes or heat exhaustion. A brief example was when there was a football game and the weather was really humid and hot. My preceptor and I watched very closely to each athlete and made sure they were drinking lots of water. The coaches would do the same as well. It showed that they really cared about their athletes instead of just the game itself. Speaking of coaches, like Daminska stated, they could be barriers in the guidelines being implemented only because ATs and coaching staff don’t always see eye to eye especially when it comes to their athletes. Overall, it is best that this topic is educated for the staff that’s included in an EAP and just overall in general that way if someone were to suspect something of such a heat stroke, they’ll know what to look for and react immediately because only 7 out 10 school implementing these strategies is terrible.
I think it’s crazy that only 28% of the AT’s (that completed the survey) responded saying that their high school uses all 6 preparedness strategies. Especially since so many athletes have passed away from heat illnesses. I agree that ATs might not be worried about their athletes suffering from heat illnesses in the colder climates but it doesn’t hurt to be prepared. Many athletes have passed away from Exertional heat stroke which could have been avoided if these strategies were put in place. One of the barriers of implementing all 6 strategies is the idea that athletes playing in these lower climates wont present with heat illness because the temperature “doesn’t get very hot”. I am currently doing my clinical rotations at a high school and we have implemented all 6 strategies. Another barrier of properly implementing all 6 strategies are the coaches. Coaches do not like cancelling/ modifying practices for any reason, even if it is too hot outside.
This was a very interesting article I was shocked at the low percentage of AT’s that reported their high school using all 6 preparedness strategies. As a retired athlete and to have tons of experience of being out in the heat due to summer sports I feel like these guidelines are very important. Even in the states that have mandates it seems like a far reach to how we can change this issue. A few barriers that come in place of implementing these guidelines could be due to climate changes in different states. Those who live in “warmer” areas may experience higher numbers of exertional heat strokes, than those in more “moderate” or “cooler” locations. Also due to the young age group that could be a huge barrier, younger athletes are just focused on being out on the field getting a win instead of their health risks. As an AT student and having previous experience working at a highs school I’ve seen it first hand. The younger age groups need more discipline meaning that as an AT we need to communicate and educate their coaches or parents about the risks. Lastly, a huge barrier could be due to the huge work load some ATs have, they are always busy especially at a high school. They have to be the first responders to every sport not only football.
At my current site I can say we have 5 of the 6 strategies mentioned. The only one that isn’t covered is the tub filled with ice. I believe some barriers for these guidelines being implemented in high schools is firstly the lack of resources. Some high schools may not have access to a tub at all, or an ice machine capable enough to fill one. Also, some AT’s may not be experienced enough with heat illnesses to respond or react in a timely manner due to their background, or where they’re originally from not having a hot climate. At the high school level, it may be the case that the AT will have to develop the policy for initiating medical services in case of emergency and creating their own EAP from scratch. For an inexperienced AT this could prove challenging. The two least challenging strategies are monitoring the WBGT and hydration access. Every high school should have access to water for their athletes. Period. And as for WBGT, even if there aren’t the proper tools to read it on the field it’s just a quick google away for whatever area an AT may find themselves in. I thought this summary was both very informative and very alarming. The fact that a quarter of the fatalities every year happen in the cooler regions should prompt them to take heat illness prevention way more seriously than this survey suggests they do.
I am a student athletic trainer currently placed at a junior college, however, we do not meet all of the standards for preventing heat illness according to this article. Currently, at my site we do not have access to a cold water tub for immersion because the practice field is a 5 minute drive away from the athletic training room at a community field that is used by multiple teams. The field does have hoses and access to cold water but there is no immersion tub. The barriers that some high schools may come into contact with is financial issues. I know the high school i grew up in did not have an athletic training room let alone an immersion tub because the school could not afford it. I think location of the athletic training room in comparison to the field can be a barrier as well. Some teams have to travel to their practice field and have to use the facilities that are provided for them and they don’t have the ability to travel with a lot of equipment. I agree with a lot of the viewpoints that are presented in the comments in this article. I think it is very alarming that 7 out of 10 football programs are
NOT implementing key heat-stroke strategies. Heat illnesses are very serious and should be treated as such. I also agree with the viewpoint that it is not okay that only 28% of athletic trainers responded to this survey. I think that maybe some of the statistics may present differently if more athletic trainers responded to the survey. Recently, I traveled with my football team to North Carolina for an away game that was played at a high school field. The weather was extremely hot and humid and there was concern from my preceptor about heat illnesses that day. Unfortunately, two athletes ended up getting transported that day to the hospital due to extreme dehydration. However, my point in bringing this up is because my team was in a foreign place and the host team did not have access to the facilities except for the locker rooms inside this high school. If it came to it we only had access to a cold shower that we would’ve had to walk up a couple of flights of stairs to access. Ultimately, i don’t think you could ever be prepared enough for any type of heat illness. It is always better to be over prepared rather than not prepared at all and risk someone possibly dying because of it.