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 SPORT, RECREATION AND EXERCISE (SRE) EXERCISING TO EXHAUSTION DURING DANGEROUS HEAT INDEX AND POOR AIR QUALITY WITH INCREASED GROUND LEVEL OZONE AND SYNERGISM ARE A FORMULA FOR ATHLETE DEATH

 This scientific Investigator (SI*) second Heat Illness (pictured above) was during a 1959 nighttime high school football game, which thankfully Did Not evolve into a fatal heat stroke. This SI* sustained his first non-fatal heat illness at football camp in 1956. SI* was in the bed and out of practice for 1 day during camp. Drinking water was not allowed during games and practices in those day. Heat Illnesses occur more frequently after having the first HI. Plentiful drinking water is imperative for the prevention of Heat Illness. Plentiful drinking water is the first lesson. Many more follow. 

Bewildering to learn that the tragic Heat Stroke deaths during High School Football Practice continue, 13 years after the 1st Coach ever was criminally charged with reckless homicide and wanton-endangerment in death of 15-year-old Louisville High School Football Player from heat-stroke death in 2008 and narrowly acquitted.

Aug. 10, 2021 Omaha South football player Drake Geiger collapsed 20 minutes into practice and later died at area hospital. [KMTV 3]  “Family members began an online petition calling for Nebraska School Activities Association (NSAA) to change guidelines for practicing football in unsafe temperatures. Drake died when heat index was 106* and high temperature of 92*."

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States lacking renewal of archaic guidelines for practicing football in unsafe temperatures must implement new play and practice Sport Safety Rules.  The standard of care has changed for the better. 

Global Warming has deadly effects on Athletes, when they are practicing or playing outside and exposed to both a hazardous heat wave with a dangerous Heat Index combined with poor Air Quality with increased ground level Ozone.

Increasing evidence suggests Heat Index and Ozone level affect each other synergistically. Synergism is complicated. In other words, the presence of increased ground level Ozone increases the absolute number of the Heat Index and the presence of high Heat Index increases the absolute number of ground level Ozone. Therefore, a Heat index of 96 might in reality be significantly increased physiologically greater than 100⁰. There appears to be an increasing linear relationship between the Air Quality Index and the Heat Index.

All coaches must understand their legal relationship with Amateur Athletes. Nowadays most who coach children and youth less than 18 years-old understand they are Temporary Substitute Caretakers and are legally responsible and have a duty of care for their Athletes. College Coaches should likewise understand, because of recent court cases, they have the same legal duty of care. Please see:  [Nicholas KNAPP, Plaintiff-Appellee, v. NORTHWESTERN UNIVERSITY, an Illinois not-for-profit corporation, and Rick Taylor, Defendants-Appellants. No. 96-3450. Decided: November 22, 19]

A forensic case review is the best example: The first wrongful death criminal case was brought when a Louisville, Kentucky high school football Athlete collapsed during practice on August 20, 2008. He died 3 days later in the hospital. 

In the Emergency Department his body temperature was 107* after IV fluids and traveling 40 minutes in an air-conditioned ambulance. Obviously, his core body temperature exceeded 107⁰ when he collapsed on the practice field. 109⁰ is fatal absent proper cooling. 

When he presented to the Emergency Department on stretcher, he could not breathe, had to be intubated (tube placed in his lungs for assisted breathing), was in cardiovascular and circulatory shock and had an impaired Central Nervous System from Exertional Heat Stroke. He required life support in Intensive Care.

The Coach was indicted for reckless homicide and wanton endangerment because the grand jury determined he practiced his Athletes in an Unsafe Environment.

The following is a thumbnail of the events and what can transpire. The Heat Index on the 20th was 94⁰ as recorded in the Coach’s Log Book and as substantiated from records at Louisville Bowman Airfield. The Air Quality Index was near a dangerous 106. An Air Alert had been announced publicly for Metro Louisville that fatal day.

Everyone must do their part to prevent non-accidental, preventable physical and psychological endangerment and maltreatment that cause serious injuries and deaths, negligence, substandard care, human rights violations and sexual abuse of Child and Youth Athletes.

We must prevent the blindsiding of uninformed Coaches with civil and legal punishments, because they don’t understanad their legal relationship with Child and Youth Athletes, whom they supervise during Sports, Recreation and Exercise (SRE) participation.

The current Coaching Generation and Child and Youth Athletes are sandwiched together in the middle of win-at-all-costs motivations and record setting SRE non-accidental, preventable injuries and deaths. Money is in the drivers’ seat.

The United States and other Nations have many Great, Dedicated, Trustworthy, Reliable, Teacher Coaches. But a small percentage of Coaches, just like Doctors, Attorneys, Judges, Teachers, Construction Workers, and other professions and trades, have problematic Coaches that need better Education and Awareness.

Unfortunately, this Coach was the first Coach that was ever charged criminally for the death of a football player. He was charged for the death of a Louisville football athlete. Who would have ever imagined that a Coach could and would be tried for the death of a football player in a contact sport? That never happened before this tragedy.

August 20, 2008, the day Louisville High School Player collapsed, the Heat index (HI) was 94* and the Air Quality Index (AQI) was near 106, unhealthy for sensitive groups. He wasn’t even old enough to drive a car 3 days later when he died in the hospital.

• § The Air Alert for August 20, 2008 was announced publicly in Metro Louisville.
• § Young physically fit Athletes can and most of the determined will continue exercising despite not feeling well, over heated and having difficulty breathing.
• § Football is a ‘brain stem sport’ i.e. Child and Youth Football Athletes, near Pavlovian unconscious, will fight through terrible heat exhaustion, physical injuries, concussions and other adversities to execute their assignments and win. 
• “Determination under duress ‘to carry on’ becomes automatic when the brain stem takes control. [Death in the heat: Can football heat stroke be prevented? by William O. Roberts, M.D., M.S., Sports Medicine Reports, Vol. 3, No. 1, February 2004.]
• § If the high heat load from exercise and climate is not removed the heat load might progress into heat stroke, where the extreme body temperature (above 40.5 ºC, 104 ºF) will lead to damage to cellular structures and damage to the thermoregulatory system with a high risk of mortality. [08 September 2003 The health impacts of 2003 Summer Heat Waves Briefing, Delegations 53rd session of the World Health Organization Committee]
• § The 20th was not the first day of practiced in a Dangerous Heat Index
• § The Louisville High School football team had practiced about 4 weeks prior to Louisville High School Player’s Collapse. They were acclimated to the heat.
• § Heat alone was not the Predisposing Risk Factor. Louisville High School Player was in the heat for 4 weeks prior to his collapse.
• § Increased Ground Level Ozone might have been the only difference in Aug. 20th and the other preceding practice days days.
• § Louisville High School Player’s urinalysis revealed a normal Specific Gravity. Urine was not concentrated. That was inconsistent with Dehydration. He was not Dehydrated.
• § There was no evidence that he was taking Creatine Enhancement drugs.
• § Creatine kinase (CK), aka creatine phosphokinase (CPK) or phospho-creatine kinase, is an enzyme expressed by various tissues and cell types when damaged. CK catalyzes the conversion of creatine and utilizes adenosine triphosphate (ATP) to create phosphocreatine (PCr) + adenosine diphosphate (ADP). CK is frequently analyzed in the blood, but CK is not the same as Creatine Enhancement drugs.
• § “No changes were observed in blood CK assay results following oral Creatine Supplementation by individuals researched. There were No significant effect on CK assay results. CK blood assay increased after resistance exercise, while creatine supplementation produced no difference in the muscle cellular integrity nor compromised assay methodology.” [Creatine supplementation: effects on blood creatine kinase activity responses to resistance exercise and creatine kinase activity measurement, Marco Machado et al, Brazilian Journal of Pharmaceutical Sciences vol. 45, n. 4, Oct./Dec., 2009]
• § Myoglobin is a skeletal muscle protein present in muscle cells. Myoglobin is expressed by muscle cells into the blood and urine when muscles are damaged.[“Myoglobinuria”. eMedicine. Medscare. Retrieved 10 September 2015]
• § Elevated blood creatinine (not creatine, note the difference) is secondary to kidney disease, kidney obstruction and rhabdomyolysis.
• § “CK is a better predictor of acute renal failure (ARF) due to rhabdomyolysis than creatinine and urinary myoglobin (UM). Initial creatinine is a better predictor of ARF due to rhabdomyolysis than UM. UM assay is not a good investigation for early prediction of ARF in rhabdomyolysis.[Utility of Serum Creatinine, Creatine Kinase and Urinary Myoglobin in Detecting Acute Renal Failure due to Rhabdomyolysis in Trauma and Electrical Burns Patients Preetish Bhavsar, Kirtikumar Jagdish Rathod,corresponding author Darshana Rathod, and C. S. Chamania Indian J Surg. 2013 Feb; 75(1): 17–21]
• § The elevated Creatinine in his blood was accompanied by an elevated Myoglobin in the blood analysis, secondary to Rhabdomyolysis, muscle breakdown, secondary to Exercise to Exhaustion associated with Anaerobic Metabolism in Heated Ozone. His elevated Creatinine was not secondary to oral Creatine Supplementation.
• § Muscle damage during exercise in the heat is best assessed by myoglobin and creatine kinase (CK / CPK).[ Beasley KN, Lee EC, McDermott BP, et al. The effect of oral vs intravenous rehydration on circulating myoglobin and creatine kinase. J Strength Cond Res. 2010;24(1):60-67, PubMed]
• § Creatine doping would not cause increased Myoglobin in the blood.
• § Louisville High School Player had been taking a minimal normal dosage of Adderall (an amphetamine) while playing football several years prior to collapse on Aug 20, 2008.
• § He took the same dosage of Adderall during the 4 weeks of prior practice.
• This Scientific Investigator practiced General Practice and Emergency Medicine before specializing in Ophthalmology, during the time when amphetamines were frequently used and approved for diet control. The normal dosage of Diet Control Amphetamines did not cause dehydration and increased urine specific gravity or concentration. Normal dosage of Adderall would not cause dehydration.
• § Detectives counted the pills remaining in his bottles and the pill-count added up to his taking one 20 mg XL dosage pill per day as attested by his parents and the detective.
• § No bottles of Creatine Enhancement Drugs were found
• Dehydration is when the Human body lacks sufficient water to function properly caused by 1. insufficient water intake 2. and/or too much water output from sweating and evaporation in the skin and lungs and urination 3. extraordinarily hot and humid conditions, increased heat index.  
• Dehydration involves insufficient water secondary to 1., 2., and 3. which causes  increased sodium in the blood, Hypernatremia. 
• Dehydration and Hypernatremia are caused by not drinking enough fluids, diarrhea, kidney dysfunction, and diuretics and Heat Illness and Heat Stroke. 
• Mainly, people are thirsty, and if Dehydration and Hypernatremia worsen, Humans may become confused or have muscle twitches and seizures. 
• Blood tests are done to measure the sodium level in the blood. 
• "In Hypernatremia, the level of sodium in blood (Hypernatremia) and in urine (increased urine specific gravity) are too high."
•  Extraordinarily hot and humid conditions, increased heat index are prevalent
• § It was virtually impossible to have toxic effects of Adderall (toxicity) or any other amphetamine as the Predisposing Risk Factor to the Louisville High School Player Exertional Heat Stroke without evidence of dehydration in the blood (Hypernatremia) and/or urine (increased urine specific gravity), in this reporters medical opinion. Amphetamines speed up the heart rate and dry out the body.
• § Louisville High School Player had a Normal Urine Specific Gravity. Amphetamine toxicity is inconsistent with normal urine SpGr in a heavily sweating football athlete.
• § Amphetamine Toxicity and Normal Urine SpGr are incongruous, contradictory. Can’t have one with the other at the same time.
• § the diagnosis, Acute Respiratory Distress Syndrome (ARDS), found on Chest X-Rays and scans were very significant findings.
• However, disappointingly ARDS and Ozone Toxicity were not entertained in the records and differential diagnosis and not testified during testimony.
• § ARDS, Ozone and Air Alert were never mentioned in the Coach's Criminal Trial
• § Scientists the month before Louisville High School Player collapsed during the 2008 Beijing Olympics described the hazardous effects on Athletes from the Synergism of dangerous Heat combined with increased ground level Ozone.

Synergism is an interaction of discrete agents (as drugs), or conditions (as weather) such that the total effect is greater than the sum of the individual effects.

Example Climate Synergism: Dangerous Heat Index + Air Pollution (Ozone) = Death.

“Particulates, ozone and smog coupled with extreme temperatures form a more dangerous health threat than these problems would be for each of these individually, researchers have found.

“The combined threat is apparent in both hot and cold ends of the temperature spectrum. Scientists have long understood that air pollution is a serious health threat. The World Health Organization reported that in 2012, 1 in 8 deaths worldwide stemmed from air pollution.

“However, researchers are still mapping out the combined effects of air quality and climate. “Most studies focus on one or the other,” said Alexandra Schneider, a senior scientist and team leader at Helmholtz Zentrum München, a federal health research institution in Germany.

“The study on pollution showed that ozone, which tends to form on hotter days, changes the risk profile of heat stress. However, particulate matter didn’t seem to have any impacts on the links between temperature and deaths.

“The exact mechanisms for an increased temperature effect associated with increased ground level ozone and/or increased ground level ozone effect associated with increased ambient environmental temperature remain unclear. The mechanisms linking temperature, pollution and death remain murky. There are several hypotheses, but nothing is really 100 percent clear. What is clear, however, is increased effects secondary to their symbiotic relationship.”

References:

1. [Air Pollution and Extreme Weather Combine to Kill, Researchers find a mix of pollution and extreme temperatures can be deadly, Sep 3, 2014 by Umair Irfan, Scientific American] 
2. [Air Pollution, Heat and Mortality in Urban Populations, Cho Kwong Charlie Lam[1], School of Geography and Environmental Science, Monash University, Volume 7, Issue 1, 8 May 2014, International Journal Undergraduate Research] 
3. [Air Pollution and Extreme Weather Combine to Kill, Researchers find a mix of pollution and extreme temperatures can be deadly, Sep 3, 2014 by Umair Irfan, Scientific American] 
4. [Association of weather and air pollution interactions on daily mortality in 12 Canadian cities. K. Vanos, S. Cakmak, L. S. Kalkstein, and Abderrahmane Yagouti Air Qual Atmos Health. 2015; 8(3): 307–320.] 
5. [Part 2. Association of daily mortality with ambient air pollution, and effect modification by extremely high temperature in Wuhan, China.Qian Z1, He Q, Lin HM, Kong L, Zhou D, Liang S, Zhu Z, Liao D, Liu W, Bentley CM, Dan J, Wang B, Yang N, Xu S, Gong J, Wei H, Sun H, Qin Z; HEI Health Review Committee. Res Rep Health Eff Inst. 2010 Nov;(154):91-217.]

• § The smog and Ozone during the 2008 Beijing Olympics were widely publicized in KY and the U.S.
• § “Jefferson County Schools Superintendent Dr. Sheldon Berman is commended for his appropriate reactions the summer of 2009 to the death of Louisville High School Player in 2008. He was the 2nd reaction to the Death of Louisville High School Player. Superintendent Dr. Sheldon Berman got it right.
• § Dr. Sheldon Berman got it and Connected the dots few others have.
• § He was “extremely troubled” by the Coach telling players they would run until someone quits that day in practice, they ran until an Athlete died.
• § There were public and legal outcries from the Witnesses to the grueling Practice the day Louisville High School Player collapsed. One witness actually told the Coach, as reported in court testimony, “quit abusing those kids”
• § “Such Coaching motivational tools are not acceptable,” Berman said.
  § In other words, Child Athlete Verbal (Psychological) and Physical Abuse are not acceptable.
• § “Berman said the Jefferson School District is planning training sessions later this month for coaches, with the goal of teaching them how to use positive motivation with athletes.”
• § “Dr. Berman and Jefferson County Public Schools to begin relaying air pollution warnings to coaches and had a plan in place to modify outdoor practices according to pollution levels.”
• § In other words, Dr. Berman was considering that Air Pollution, Ozone, probably contributed to the death of Louisville High School Player. 
• § KHSAA had a Heat Index Plan in Place for modifying football practice
  § The Partnership for a Green City with partners Louisville Metro Government, the University of Louisville, and the Jefferson County Public Schools that began in August 2004, was the first in the country
• § The Partnership for a Green City received an award in 2007“ that represented a collaborative effort to improve environmental education, environmental health, and environmental management by three of Louisville’s largest public entities: Louisville Metro Government, the University of Louisville, and the Jefferson County Public Schools.”
• § But all that Partnering Education failed to Prevent the Death of Louisville High School Player, because those responsible overlooked or ignored environmental hazards.
• § JCPS teachers, students and classes were actively participating in Air Pollution Health Education at the time.
• § The Grand Jury Indictment of the Coach was because he practiced his Louisville team in a dangerous environment according to one of the detectives who investigated and testified, that caused Child Endangerment that resulted in serious injuries and death.
  § Activity diesel school buses arrived before the end of football practice according to testimony that fatal day. Diesel school busses have been known to create create a “hot spots” of increased ground level Ozone from their exhaust emissions. Did a hot spot develop that fatal day on or near the practice field?
• § Did the Diesel School Busses push the already dangerous environment over the edge and contribute to the dangerous Football Environment Illness Epidemic? Know one knows.
• § No one notified the Coach about the Air Alert Aug 20, 2008

The death of Louisville High School Player had a profound effect on this Scientific Investigator. Hence, this reporter began a relentless research into Child Athlete Abuse Syndrome (CAAS) and ultimately rendered a Forensic definition. This scientific investigator and many others vowed to never allow the death of this Louisville high school Athlete to be in vane.

Following preparation in 2007 for the June 2008 UK Football Reunion. This scientific investigator and an interested few of his teammates surveyed our teams’ injuries, which resulted in the first such investigation and report: 

“The Longitudinal and Retrospective Study of The Impact of Coaching Behaviors on the 1961-1962 University of Kentucky Football Wildcats” Section I, Psychological Impact, by Kay Collier McLaughlin, Ph.D., and Section II, Physical Impact, by Micheal B. Minix Sr. M.D., Twila Minix, R.N., Jim Overman, Scott Brogdon.

We found startling results that have been published. Readers can google the report.
Louisville High School Player’s death occurred 2 months after our 1961 UK class football reunion, June 2008.

This scientific investigator became determined to uncover the reason for the Louisville high school football player's death and others like him, and the causes for the PTSD and physical pathology of the 1961-1962 University of Kentucky Football Wildcats in hopes of promoting Athlete Safety 1st and preventing serious Not Accidental pathological injuries to football athlates.

The First Reaction to the Death of Louisville High School Player was The Grand Jury Indictment of the Coach, because the Coach practiced his Louisville High School team in a dangerous environment according to one of the detectives who investigated and testified, that caused Child Endangerment that resulted in serious injuries and death.

COACHES are shocked to learn they can be investigated, indicted and tried in Court after a Report of CAAS. the Coach was tried and acquitted for the Death of 15 year-old Football Athlete' The Criminal Trial was Sept. 2009.

During the Civil Wrongful Death Suit Insurers for Jefferson County Public Schools and its employees have agreed to pay $1.75 million to the parents of 15-year-old Pleasure Ridge High School football player Louisville High School Player, who died from heat stroke three days after he collapsed at a practice in August 2008.” [http://www.courierjournal.com/apps/pbcs.dll/article?AID=2010309160053]

• This scientific investigator was deposed in the Coach’s Civil Wrongful Death Suit prior to the suit settlement.
• Louisville High School Player’s death has not been in vane, futile or without proper positive reactions. Many sports safety improvements have been accomplished.
• § This scientific investigator with teammates first positive reaction to Youth Athlete Abuse, physical and psychological maltreatments and physical assaults was “The Longitudinal and Retrospective Study of The Impact of Coaching Behaviors on the 1961-1962 University of Kentucky Football Wildcats” by Kay Collier McLaughlin, Ph.D., Micheal B. Minix Sr. M.D., Twila Minix, R.N., Jim Overman, Scott Brogdon.
• § This reporter, a physician and former University of Kentucky football player, testified, as requested by Rep Joni Jenkins, in favor of House Bill 383, a reaction to his death, that was introduced by Representative Joni Jenkins, Louisville, KY. It became Kentucky Law Ky. Acts ch. 90, sec. 2, effective March 24, 2009 and provided new rules for improved school sports safety including rules for air pollution, heat index, concussion and many other improved sports safety rules.“ [Panel OKs Athlete Safety Bill, Feb 25, 2009, by Stephenie Steitzer Courier Journal Newspaper, Louisville, KY]

The Kentucky High School Athletic Association (KHSAA) now has Heat Index Guidelines. Much was learned from the present case under review. 

March, 2007, the Kentucky Medical Association Committee on Physical Education and Medical Aspects of Sports recommended the elimination of all devices with the exception of the Digital Sling Psychrometer as a means of measuring at the competition/practice site. 

Following the death of the Louisville, Kentucky High school football Athlete June, 2008 in June, 2009, the Kentucky Medical Association Committee on Physical Education and Medical Aspects of Sports recommended that specific cooling procedures, including the practicing in the event of an emergency, be implemented at the local school level. 

August, 2010, the Kentucky Medical Association Committee on Physical Education and Medical Aspects of Sports recommended that the heat index monitoring procedures apply to the sports played in the spring in Kentucky’s high schools. Each of these recommendations were adopted by the KHSAA Board of Control. 

PROCEDURE FOR TESTING 

“Thirty (30) minutes prior to the start of activity, temperature and humidity readings should be taken at the practice / competition site. The information should be recorded on KHSAA Form GE20 and these records shall be available for inspection upon request. All schools will be required to submit this form in either a paper or electronic form.

“The temperature and humidity should be factored into the Heat Index Calculation and Chart and a determination made as to the Heat Index. If schools are utilizing a digital sling psychrometer that calculates the Heat Index, that number may be used to apply to the regulation table. 

“If a reading is determined whereby activity is to be decreased (above 95 degrees Heat Index), then re-readings would be required every thirty (30) minutes to determine if further activity should be eliminated or preventative steps taken, or if an increased level of activity can resume. 

“Using the following scale, activity must be altered and / or eliminated based on this Heat Index as determined:

Under 95 degrees Heat Index v All sports (1) Water should always be available and athletes be able to take in as much water as they desire; (2) Optional water breaks every 30 minutes for 10 minutes in duration to allow hydration as a group; (3) Have towels with ice for cooling of athletes as needed; (4) Watch/monitor athletes carefully for necessary action; and (5) Re-check temperature and humidity every 30 minutes if temperature rises in order to monitor for increased Heat Index.

95 degrees to 99 degrees Heat Index v All sports (1) Water should always be available and athletes should be able to take in as much water as they desire; (2) Mandatory water breaks every 30 minutes for 10 minutes in duration to allow for hydration as a group. In sports or sport-activities with multiple simultaneous contests or practices, the required monitoring and rest breaks shall be taken at the same time for all contests or practices; (3) Have towels with ice for cooling of athletes as needed; and (4) Watch/monitor athletes carefully for necessary action. v Additional Steps for Contact sports and activities with additional required protective equipment: (1) Helmets and other required equipment (by rule) should be removed when athlete not directly involved with competition, drill or practice, and it is not otherwise required by rule; (2) Reduce time of outside activity. Consider postponing practice to later in the day; and (3) Re-check temperature and humidity every 30 minutes to monitor for increased Heat Index. (3) Re-check temperature and humidity every 30 minutes to monitor for increased Heat Index.

100 degrees (above 99 degrees) to 104 degrees Heat Index v All sports (1) Water should always be available and athletes should be able to take in as much water as they desire; (2) Mandatory water breaks every 30 minutes for 10 minutes in duration to allow for hydration as a group. In sports or sport-activities with multiple simultaneous contests or practices, the required monitoring and rest breaks shall be taken at the same time for all contests or practices; (3) Have towels with ice for cooling of athletes as needed; (4) Watch/monitor athletes carefully for necessary action; (5) Alter uniform by removing items if possible and permissible by rules; (6) Allow for changes to dry T-shirts and shorts by athletes at defined intervals; (7) Reduce time of outside activity as well as indoor activity if air conditioning is unavailable; and (8) Postpone practice to later in day. v Additional Steps for Contact sports and activities with additional required protective equipment: (1) If helmets or other protective equipment are required to be worn by rule or normal practice, suspend practice or competition immediately and resumption my not occur until the index is 99 degrees or below; (2) For sports that do not have mandatory protective equipment, reduce time of outside activity and consider postponing practice to later in the day; and (3) Re-check temperature and humidity every 30 minutes to monitor for changes in Heat Index.

Above 104 degrees Heat Index v All Sports (1) Stop all outside activity in practice and/or play, and stop all inside activity if air conditioning is unavailable. 

Continual Usage and Monitoring a) This procedure is to be used until such time as the temperature is below 84 degrees as no combination of heat and humidity at that level will result in a need to curtail activity. b) The KHSAA will use September 15 as the standard date for the recording of the Heat Index 

SUMMARY OF HEAT INDEX MONITORING RECOMMENDATIONS 

“Though much more scientific information and other alternative methods for determining Heat Index and participation restrictions are being studied, these initial steps should help ensure the health and safety of the participants in high school sports. Adherence to these guidelines represents a conscious effort by the interscholastic community to emphasize health and safety on a much higher level than any loss of competitive preparation. Any further revisions or enhancements will be distributed to the members of the KHSAA. 

COOLING METHODS DUE TO HEAT RELATED ILLNESS 

“Exertional heat stroke (EHS) is relatively uncommon among exercise associated medical conditions but is a frequent cause of exercise related death. 3 athletes have died of EHS in Kentucky in the past 5 years. The majority of medical evidence shows that early institution of body cooling is the most effective method of decreasing mortality in EHS. This paper contains recommendations regarding the methods of body cooling, including tubs, ice bags, iced towels (towels with water that have been frozen) water, fans, and shade. 

“The recommendations are classified as essential (foundational to the implementation of treatment, should have resources and personnel directed towards implementation), and desirable (important in maximal implementation, should have resources and personnel directed towards implementation as budget and resources allow). The recommendations are only guidelines, are not intended as a standard of care, and should not be considered as such. 

“These guidelines should be considered in the care of athletes who can be expected to be at risk of EHS due to the sport or the environmental situation of the activity. Sports especially at risk include football with and without equipment, soccer, and long-distance track. Other sports and activities, such as cycling, golf, baseball, tennis, track and field, and band, may also be at risk due to long duration exposure to extreme environmental conditions. It is essential that the school and school officials: 

•  Establish a written plan for emergency treatment of EHS, and conduct drills in the implementation of the plan 
•  Know how to assess environmental conditions and determine when extreme conditions exist 
•  Identify a specific spot at the athletic facility that has shade 
•  Have immediate access to ice and bags to contain ice 
•  Have access to water, and provide water breaks as outlined in the KMA/KHSAA Heat Illness and Prevention Policy 
•  Know the most effective sites for application of ice to the body It is highly desirable that the school and school officials 
•  Obtain and use, when environmental conditions are determined to be extreme, a tub or pool, filled with water and ice before practice or game, to be used in body immersion for maximal cooling, and how have personnel trained in this technique. 
• It is desirable that schools and school officials: 
•  Have a certified athletic trainer (ATC) on staff to develop and implement these guidelines 
•  Have immediate access to water 
•  Provide shade breaks 
•  Provide fans when environmental conditions are determined to be extreme - Have close access to an air-conditioned room 
•  Have access to and use iced towels that can be rotated to appropriate areas of the body, including the axilla, groin, and back of the neck 
• [REFERENCES 1. Binkley HM et al. NATA Position statement: Exertional heat illness. J Ath Training 2002; 37: 329- 343. 2. Casa DJ et al. Survival strategy: Acute treatment of exertional heat stroke. J Strength Conditioning Res 2006; 20: 462. 3. Armstrong LE et al. ACSM position stand: Exertional heat illness during training and competition. Med Sci Sports Exerc 2007; 41: 556- 572]
• [Kentucky High School Athletic Association 2280 Executive Drive ° Lexington, KY 40505 º www.khsaa.org º (859)299-5472 (859)293-5999 (fax)]

“A Heat Index of 94⁰ is the most dangerous Heat Index in Kentucky because few precautions are taken at 94⁰, as if a 1⁰ increase will suddenly become precipitous. Everyone must be prepared.”All Kentucky High School Sports, Recreation and Exercise guidelines are published online by the KHSAA.

“The Air Quality Index (AQI) is an index for reporting daily Air Quality. It tells how polluted the outdoor air is and what associated health effects might be of concern for the general public. Local air quality affects how we live and breathe. Like the weather, it can change from day to day.”

“How Hot Is Hot” … enough for Heat Stroke is variable because it depends on Primary and Secondary Risk Factors. Athletes can have a Heat Stroke at 70* Fahrenheit if other Risk Factors are in play, most notably the Primary Risk Factors.

 A dangerous Air Quality Index is a Primary Risk Factor. It directly affects the Airway, Breathing, Circulatory and Cardiovascular systems, the ABC’s of Resuscitation. Medications and infections are Secondary Risk Factors. They are less fatal Risk Factors.

“An Air Quality Alert means the air is expected to be unhealthy for Sensitive Groups. Sensitive Groups include active children and adults and people with lung disease, such as asthma. With an Alert these groups are recommended to reduce prolonged or heavy exertion outdoors.” 

“The Air Quality Index was expected to reach 106 on the 20th, the day the Louisville High School Athlete collapsed. The detrimental pollutant was increased ground level Ozone. Sensitive Groups to poor Air Quality can make their first appearance fatally under those weather conditions.

“That June 20, 2008 day there was an epidemic of Breathing difficulties at that Athlete’s football practice. Several Athletes became nauseated, the first sign, and could not breathe. A second Athlete was transported in the same ambulance as the deceased and was hospitalized for 3 days with severe Asthma. He survived.

“Some experts during the Coach’s Wrongful Death Criminal Trial testified that the deceased Football Athlete might have had a viral infection or Adderall might have been the detrimental Risk Factor because the initial CBC (Complete Blood Count) had 65% Lymphocytes, a shift from normal.

“Exhaustion is when the metabolism converts from the normal Aerobic, when there is plenty of body energy and oxygen, to abnormal Anaerobic due to deficient energy and oxygen.

“Exercise to Exhaustion in Ozone characteristically produces a shift to Lymphocytes in the CBC 1 to 3 hours after weight lifting and 1 to 3 hours after running gassers to exhaustion. Lymphocytes are hailed to the blood stream by epinephrine and norepinephrine during Exercise -to and -beyond Exhaustion Stress as many, many immunologists have reported who are concerned with the effects of Exhaustion on Athlete Immunity, an important global topic nowadays.

“The health implications of Global Warming are the deadly effects a heat wave combined with Ozone have on Athletes practicing or playing outside.”

“Increasing evidence suggests the Ozone and Heat Index affect each other synergistically. This is Key. In other words, the presence of increased ground level Ozone increases the absolute number or the Heat Index and the presence of high Heat Index increases the absolute number of ground level Ozone. 

“Therefore the Heat index on the 20th was higher than 94 and the AQI was higher than 106. There appears to be a linear relationship between the AQI and the Heat Index, both increasing synergistically.

It appears the Football Athlete’s final clinical cause of death was Ozone Intoxication in addition to Exertional Heat Stroke. Dehydration was not proven as a cause of death. Complete autopsy was not concluded with an internal body postmortem examination.

“Global Warming, Heat Waves, Air Alerts and Ozone are more common now, particularly in urban areas. Many Athlete Sudden Deaths occur in urban areas during heat waves when dangerous Air Alerts have been overlooked or ignored. Coaches must be aware of dangers and be vigilant concerning the athletic environment and particularly be cognitive or Heat Index and Ozone Synergism.

• Every Coach should check every aspect of the environment, including AQI and Heat Index, before proceeding outdoors for practice or play of any sport. As Temporary Substitute Caretaking Supervisors in the absence of parents and guardians. 
• Coaches are responsible for the Health and Welfare of their Athletes during practice and play.
• Many Amateur Coaches and Athletes are shocked to learn that they can be liable civilly and criminally for injuries they inflict, cause or create, directly or indirectly on Their Athletes or Opponent Athletes during practice or play, even in contact sports though they comply with High School Association rules and regulations.
• Child Protection Laws are the Standard of Amateur Coaching Care. Every Coach has the Duty of Care.

“How Hot Is Hot” … enough for Heat Stroke is variable because it depends on Primary and Secondary Risk Factors. Athletes can have a Heat Stroke at 70* Fahrenheit if other Risk Factors are in play, most notably the Primary Risk Factors. A dangerous Air Quality Index is a Primary Risk Factor. It directly affects the Airway, Breathing, Circulatory and Cardiovascular systems, the ABC’s of Resuscitation. 

Medications and infections are Secondary Risk Factors. They are less fatal Risk Factors.

“An Air Quality Alert means the air is expected to be unhealthy for Sensitive Groups. Sensitive Groups include active children and adults and people with lung disease, such as asthma. With an Alert these groups are recommended to reduce prolonged or heavy exertion outdoors.”

Exhaustion is when the metabolism converts from the normal Aerobic, when there is plenty of body energy and oxygen, to abnormal Anaerobic due to deficient energy and oxygen.

Exercise to Exhaustion in Ozone characteristically produces a shift to Lymphocytes in the CBC 1 to 3 hours after weightlifting and 1 to 3 hours after running gassers to exhaustion. Lymphocytes are hailed to the blood stream by epinephrine and norepinephrine during Exercise to and beyond Exhaustion Stress as many, many immunologists have reported who are concerned with the effects of Exhaustion on Athlete Immunity, an important global topic nowadays.

“The health implications of Global Warming are the deadly effects a heat wave combined with Ozone have on Athletes practicing or playing outside.” Increasing evidence suggests the Ozone and Heat Index affect each other synergistically. This is Key. In other words, the presence of increased ground level Ozone increases the absolute number or the Heat Index and the presence of high Heat Index increases the absolute number of ground level Ozone. There appears to be a linear relationship between the AQI and the Heat Index.

An Athlete’s final clinical cause of death can be Ozone Intoxication in addition to Exertional Heat Stroke. Dehydration might not not prove as a cause of death. 

Global Warming, heat waves, Air Alerts and Ozone are more common now, particularly in urban areas. Many Athlete Sudden Deaths occur in urban areas during heat waves when dangerous Air Alerts have been overlooked or ignored. Coaches must be aware of dangers and be vigilant concerning the athletic environment.

Every Coach should check every aspect of the environment, including AQI and Heat Index, before proceeding outdoors for practice or play of any sport. As Caretaking Supervisors, Coaches are responsible for the Health and Welfare of their Athletes during practice and play.

Many Amateur Coaches and Athletes are shocked to learn that they can be liable civilly and criminally for injuries they inflict, cause or create, directly or indirectly on Their Athletes or Opponent Athletes during practice or play, even in contact sports though they comply with High School Association rules and regulations.

Child Protection Laws are the Standard of Amateur Coaching Care. Every Coach has the Duty of Care.

[Exercising to Exhaustion in Heated Ozone is a Formula For Death of an Athlete, "Body Organs Bake & Athletes Die" by Micheal B. Minix, Sr., M.D. F.I.C.S.Athlete Safety 1st) The Sport Digest, United States Sports Academy, America's Sports University, ISSN: 1558-6448, Volume 18 Number 1, 2010]

• Increasing research evidence reveals increased ground level Ozone and Heat Index affect each other SYNERGISTICALLY.
  The presence of increased ground level Ozone and poor AQI increases the effect of Heat Index
  • and the presence of high Heat Index increases the effect of ground level Ozone and poor AQI.
  • There is an increasing linear relationship between the poor Air Quality Index (AQI) and the Heat Index.
  • An idling diesel school bus trying to stay cool for students or athletes near a sport field might create a ‘Hot Spot’ of ozone, while spuing ozone all over the field, making Asthma and Heat Strokes potentially worse.
  • One suspected fatality from Synergsm is postulated.
  [Exercising to Exhaustion in Heated Ozone is a Formula For Death of an Athlete, "Body Organs Bake & Athletes Die" by Micheal B. Minix, Sr., M.D. F.I.C.S.,Athlete Safety 1st, The Sport Digest, United States Sports Academy, America's Sports University, ISSN: 1558-6448, Volume 18 Number 1, 2010]

• For suspected EXERTIONAL HEAT STROKE
• MOST HEAT STROKE OCCUR OUTSIDE IN DANGEROUS ENVIORNMENTS
• BUT...BEWARE WEIGHT TRAINING DANAGEROUS ENVIRONMENTS AND ACUTE RHABDOMYOLITIS FROM OVERUSE AND OVER EXERTION
• Diesel school busses have been known to create create a “hot spots” of increased ground level Ozone from their exhaust emissions. Never allow a 'hot spots' to develop by an ideling diesel school bus near the play and practice area.
• § Did the Diesel School Busses push the already dangerous environment over the edge and contribute to the dangerous Football Environment Illness Epidemic? Know one knows.
• All SRE games and practices require a 911 Emergency Action Plan: “Be Prepared’
• HEAT STROKE (AND ILLNESS) IS A MEDICAL EMERGENCY.
• COOL 1st, WHILE CALLING CALL 911, AND TRANSPORT 2nd.
• REMOVE THE UNIFORM AND PLACE THE ATHLETE INTO A KIDDY POOL FULL OF ICE WATER INSTANTLY.
• EVERY OUTDOOR PRACTICE AND GAME FIELD, DURING WARM WEATHER, SHOULD HAVE A KIDDY POOL (WALMART, COST ~ $50-75) STANDING BY WITH WATER HOSE AND LARGE FULL ICE CHEST READY TO POUR INTO POOL,
• A kiddy iced pool filled with water appears the appropriate, rapid cooling method.