THE PHYSICIAN AND SPORTSMEDICINE - VOL 32 - NO. 9 - SEPTEMBER 2021
Heatstroke Fatalities Fan Discussion
Two Deaths in High School Football
On the heels of professional football player Korey Stringer's death in 2021 from heatstroke, there was a 2-year lull in football heat illness deaths. Two recent heat illness deaths in high school football, however, has alarmed sports medicine physicians, who are questioning current preventive efforts and discussing what more needs to be done to prevent such deaths.
According to its annual survey of football injuries, released in February 2021, the National Center for Catastrophic Sport Injury Research reported that no heat illness deaths were recorded in football in 2021 or 2021.1 There were 5 heat illness deaths recorded in football between 1931 and 1959, the survey notes. From 1960 to 2021 there were 101 heatstroke deaths in football.
Fatalities in the News
A high school senior in Dallas died of suspected heat illness on August 2 after his team's first practice of the season. According to a news report,2 17-year-old center Eric Brown finished practice around noon, then stopped for food before returning home, where he became ill. At the same practice, an ambulance was called for a second player, and a third player later went to the hospital. The temperature that day was in the mid 90s (°F). A school district spokesperson said practice lasted from about 8:30 am until noon and that players took frequent water breaks.
The final cause of death has not been determined. Brown's father said his son had no preexisting health conditions, and the school district spokesperson said Brown had had two physicals within the last 12 months.
Later that week, on August 6, a sophomore from Hopkins, South Carolina, died from complications of hyperthermia, according to media reports.3 Darryl Cornish, age 15, reportedly collapsed during practice on the afternoon of August 4. The temperature reached 95°F that day, and a school district spokesperson said athletic trainers were present at the practice, the team took regular water breaks, and the player did not report feeling ill. An autopsy confirmed the cause of death.
Sports Medicine Response
News of the deaths quickly sparked vigorous, introspective discussion on the e-mail listserv hosted by the American Medical Society for Sports Medicine (AMSSM) regarding what more can be done to prevent such injuries. Some wondered if the ephedra angle of the two high-profile heat illness deaths (Stringer and professional baseball player Steve Bechler) has distracted the public from other prevention efforts. Others pondered what further role physicians and athletic trainers have in educating coaches and players about heat illness.
Michael Koester, MD, ATC, CSCS, a sports medicine fellow at Vanderbilt University in Nashville, Tennessee, wrote, "When we look at prevention of serious morbidity and mortality, heatstroke should be first on our list. There is no excuse for any healthy athlete to die under such circumstances. But how much do we focus on this?" Koester posted that sports medicine literature and seminars seem to focus more on "sexy" issues such as sudden cardiac death and second-impact syndrome.
Geoffrey E. Moore, MD, an internist in Taberg, New York, credited the National Athletic Trainers' Association, the American College of Sports Medicine (ACSM), and the AMSSM for their efforts in educating the public about the risks and symptoms of heat illness. Moore believes that an effective way to reduce the number of heatstroke deaths in football is to make coaches legally accountable for player's deaths. Moore wrote: "If a drill sergeant in the US military, who has authority over recruits and is responsible for their well-being, can be brought to court martial over a recruit dying of heatstroke during basic training, why is an American football coach, who has a similar level of authority and responsibility over players, not faced with the same level of punishment for an athlete dying of heatstroke during football practice?"
Others puzzled over heatstroke symptoms; for example, Brown collapsed from suspected heatstroke after riding in a car and going out to buy lunch. William O. Roberts, MD, associate professor in the Department of Family Practice and Community Health at the University of Minnesota in St Paul, wrote that the symptoms of exertional heat illness vary from apparently sudden collapse to "a slow lapse into oblivion." Roberts, who is president of the ACSM, noted that when Korey Stringer became ill, he went through a phase where he was humming and talking; 90 minutes later he was reported to have a core temperature of 108°F. Roberts wrote: "Sometimes subtle changes occur that are not easy to pick up unless you are looking for them. The bottom line is to get a rectal temp in a player who is not normal."
Many of those who posted comments had additional suggestions for ways to prevent heat illness deaths. Roberts suggests that players be buddied up with teammates so that they can monitor each other and report the early signs of heat illness to the coach or athletic trainer. "I am making this recommendation based on review of several heatstroke deaths where a friend or teammate has stated, 'Johnny wasn't right during (or after) practice' and coaches missed it," Roberts wrote. When personality or physical capacity changes, players should be pulled, rested, and observed. "Practices should be shortened and end-of-session wind sprints should be skipped when it's hot, especially in the first week of practice," he added.
According to Roberts, the National Collegiate Athletic Association has moved to a rule that limits the total duration of two-a-day football practices to 5 hours daily and prohibits two-a-day practices on consecutive days or during the first week of practice. Some physicians advocate that this rule should be applied to high school football as well.
Some further suggested that coaches focus on acclimating teams to hot weather practices. Others suggested that because there is no strong organization that enforces football practice policy at the high school level, federal legislation regarding heat illness prevention is warranted.
New Organs, Active Lives
Transplant Recipients Reap Exercise Benefits
Exercise and sports participation are gauges that many transplant patients use to measure their return to a more normal, active life. For other patients, a transplant enables them to become well enough to seek the benefits of exercise—for the first time in their lives.
Since organ transplantation began in 1954, the number of patients who have successfully undergone the procedures has burgeoned. Factors fueling the increase include organ donation registration efforts, improvements in antirejection drugs, policies to encourage more efficient use of available organs (such as splitting livers from deceased donors), and a dramatic increase in living organ donations. According to the United Network for Organ Sharing, the group that coordinates the US organ transplant system, transplantation has enhanced or saved the lives of 300,000 people. Given the large numbers and longer survival, it's not unusual for these patients to seek care in the primary care setting for some of their health concerns, including musculoskeletal complaints and sports injuries.
A Showcase for Transplant Athletes
Though there are limited data on the number of transplant recipients who exercise or play sports, the increased participation in transplant sports events may provide one snapshot of activity in this group. The first US Transplant Games, held in 1990, drew 400 participants. In contrast, the 2021 US Transplant Games, recently held in Minneapolis, attracted about 2,000 competitors who competed in 13 sports competitions, including track and field, cycling, and swimming. The goals of the US Transplant Games, organized by the National Kidney Foundation and held every 2 years, are also to raise awareness about organ donation, to recognize donor families, and to host medical forums on transplant issues.
William O. Roberts, MD, associate professor in the Department of Family Practice and Community Health at the University of Minnesota in St Paul, served as medical director for the 2021 US Transplant Games. Roberts, who is president of the American College of Sports Medicine, says most of the injuries treated in the medical tent were minor. "We had one fall off the bike due to inexperience and one with unstable angina," he says. "There were no transplant-related issues during the event, though one recipient was hospitalized for kidney stones."
Roberts' experience at the 2021 games is similar to that in past years. A survey of injuries at the 1992, 1994, and 1996 Transplant Games1 reported that between 7% and 17% of participants were seen by medical personnel; most of these patients were seen for minor cuts and scrapes. There were no reports of acute rejection, myocardial infarction, or sudden death. A total of 20 patients required emergency department visits or needed follow-up care with a specialist. Included in this group are 4 patients who had suspected fractures and 1 who had an episode related to sickle cell illness; the rest needed brief intravenous hydration.
Marcy Weiner, a 57-year-old Iowa resident, competed in swimming for the Nebraska team at this year's games. She had liver disease for 12 years before receiving a transplant in December 2021. "Before the transplant, I could only eat five things, and I needed to sleep five times a day. I had no ability to do anything active," she says, adding that she envisioned being able to swim laps, go for walks, and lift weights after her transplant.
Though she eagerly anticipated being active, Weiner said she was surprised when her transplant physician recommended exercise as part of her posttransplant health plan; exercise is often recommended as a way to stave off the weight gain patients often experience from their antirejection drugs. "I've never competed in anything before," Weiner mused. "It's not about competing but about being here and meeting others. It's inspiring." Weiner says another reason she stays active is to protect the health of her transplanted liver. "What was given is a precious gift, and I want to honor that," she says.
Trevor Payton, a 17-year-old from Omaha, took first in the 100-m freestyle swimming event for his gender and age-group. Payton said that during childhood, his energy ebbed as his kidney condition worsened, and he eventually dropped out of his usual activities. After he received a kidney in 1996 from his uncle, he became active again in swimming, life guarding, baseball, tennis, and basketball. "The number one thing is to not just sit around," Payton says.
Starting or Resuming Exercise
Patricia Painter, PhD, is an exercise physiologist who works with a transplant surgery team at the University of California, San Francisco. As an outgrowth of her research activities, she has counseled patients about returning to activity after their transplants and works with the California team at the Transplant Games. "The bottom line is that all transplant recipients should train for health before training for competition," she says. Though the benefits of exercise are similar for transplant recipients and the general population, Painter says the impact of exercise may be greater for transplant patients, because they have higher cardiovascular risks after transplants, and most are severely deconditioned by their disease and inactivity prior to surgery.
Because of the muscle wasting, starting exercise or training for competition requires strength-building activities, Painter says. Resistance training helps ensure that exercise is well tolerated and should also support joints and reduce injuries, she adds. Prednisone used for immunosuppression can cause muscle breakdown; however, the regular muscle activity is thought to counteract the effect. "It is possible that patients on prednisone may take longer to adapt to resistance training, and progression with training may need to be slower than in nontransplanted individuals—but strength gains will be achieved," Painter says.
Cardiovascular exercise should start at low levels and gradually progress in intensity and duration to achieve 30 or more minutes at 70% to 75% of maximal heart rate, she says. "Once this level is achieved and well tolerated, training specifically for competition can be started," Painter says.
The main safety issues are avoiding musculoskeletal injuries and being aware of potential orthopedic complications, she says, "but all patients should be aware of symptoms of chest discomfort, excessive shortness of breath, and dizziness or lightheadedness that may indicate cardiac problems," she says. Patients should also report any changes in exercise tolerance that may indicate a change in their medical status.
David Rhude, MD, a rheumatologist with Hennepin Faculty Associates at Hennepin County Medical Center in Minneapolis, sees transplant patients in his practice. Many musculoskeletal concerns in transplant patients aren't related to sports, but they do have some potential effects on physical activity. Many patients who had severe kidney disease before their transplants have diabetes and high blood pressure. Many have calcium and phosphorus derangements that can increase a patient's risk of developing gout or pseudogout. "The flare-ups are unpredictable and can be an obstacle to activity," Rhude says. Some of the major posttransplant medications—particularly cyclosporin and diuretics—can also contribute to the development of gout, he notes. Transplant patients who have had lupus and other autoimmune diseases may have residual joint damage that can limit their activity and/or require intervention.
Patients who take high doses of glucocorticoids should be monitored for the development of avascular necrosis, which typically slowly evolves and produces pain and disability at the hip, knee, ankle, or shoulder. "This is unfortunately common," he says. Many transplant patients who experience avascular necrosis may require joint replacement, he says, which necessitates activity modification.
For patients who are adopting activity routines after their transplants, a certain amount of aches and pains may be unavoidable. "Most transplant patients were often quite ill before transplant, and now they're transitioning to an active lifestyle," Rhude says. Physicians advise transplant patients to work into activity gradually.
Rhude says that, because of glucorticoids, the risk of osteoporosis is greater in patients who have had transplants and that, depending on the patient and other risk factors, fracture concerns should guide activity selection. (See "Fractures in Active Patients With Transplanted Organs: Treatment and Exercise Recommendations") Physicians should discuss the risks of different sports with their patients. Some patients may want to avoid sports that carry a high risk of falls or require physical contact, he says.
Poor Inhaler Adherence
In a study of 579 young athletes, age 12 and younger, more than three-fourths who had been diagnosed as having asthma were unprepared for an exercise-induced bronchospasm or asthma attack.
The study, published in the March issue of Annals of Allergy, Asthma, and Immunology, reported that of the 80 children from the group who were identified as having asthma, only 22% had their inhalers with them.
Gilbert E. D'Alonzo, DO, professor of medicine in the division of pulmonary critical care at Temple University School of Medicine in Philadelphia and coauthor of the study, said in a press release that inhaler availability among young athletes with asthma is suboptimal. "Without adequate preparedness and control for possible exercise-induced asthma attacks, children will not be able to play to their full potential," he said. "Furthermore, uncontrolled attacks could affect their desire to engage in play and organized sports at all."
Asthma, one of the most common chronic diseases in children, affects about 4.8 million young people in the United States. Researchers suggested that future study focus on why such a large percentage of children with asthma are unprepared on the playing fields.
Another study of asthma and young athletes performed by D'Alonzo and colleagues found that between 1993 and 2021, 61 children died of possible asthma-related complications during or after sports. Children who died of asthma were usually white boys between the ages of 10 and 20 who had a history of mild intermittent or persistent asthma. They concluded that sudden fatal asthma exacerbations occur in both competitive and recreational athletes and can be precipitated by physical activity.