Transcript
This is Ray Castle, moderator for the session.
I wanna thank you so much for attending today's session.
And as we kick off sports medicine, sports emergency care symposium 1.0.
We're Puerto Rico's to have doctor Rod Walters on our as our first kickoff presentation, Give me a second.
I'm going to get the share screen so he'll go ahead and get started with excuse me.
Doctor Walters, you should have access now, I believe.
Let me just double check here one second.
Do you have access to the to you can load your presentation up?
So as he gets started, I just wanna have a couple quick housekeeping notes.
We can get right into this presentation.
We have a solid hour of content from Doctor Walters, and then also from have a chance to answer your questions during this session.
If you would, 1st starting out, just jump in the chat and let us know where you're from, and we're excited to see where you're coming from and where what you're setting is in.
As far as questions during today's session, please go to the q and a tab.
You should see there.
You can just drop your question in, and then we're gonna have several minutes from download at the end to answer questions, and then we'll also get to that as well.
So as we get started.
I wanna introduce good morning, Doctor Walters.
How are you doing today?
Good morning.
I'm doing great.
Thank you, Ray.
Thank you so much.
So I'm gonna give a quick intro for for those of you who have not read his bio, and it's just a tremendous privilege to have you here this morning, Doctor Walters.
And as you kick off, as I mentioned before, on this and inaugural sports market care symposium.
If you read the Bible, I'm not gonna take too much time because they wanna get to the meat of the of the this presentation, get you started.
That those who are in the audience have not seen that Doctor Walters is considered one of the leading emergency care experts in the country.
He has over 50 years experience in the profession and extensive experience coordinating student athlete health care.
Some of his accolades and he's inductee of the Mid America I mean, I'm sorry, Mid Atlantic.
Athletrain Association, and Nat Hall of Fame.
He has over 27 years of experience as a director of sports medicine at the university level, He's been an NAT board of directors.
He also currently serves on the NATA Professional Responsibility Athletic Training Committee.
He was Those of you may not know that the Maryland Water Region selected Doctor Walters as a lead investigator in the exertional heat stroke death of University of Maryland student athlete, Jordan Mayer, that which claimed national media attention and on his investigative work.
In 2019, he also has worked with the Braden Bradford, exertional heat stroke, in Garden City Community College, as well as other cases as well.
He does extensive work in the emergency action reviews, cushion care of sudden cardiac death and general orthopedic surgery.
His company also provides concussion monitoring services for the Big 12.
As he coordinates their football medical observer program.
He's also highlighted that he was the lead, a t spotter, for the 2019 Super Bowl, and he's been a NFL spotter since 2013.
Lastly, he serves on the athletic medicine review boards for University of Maryland and the University of Georgia.
And then on the side of that, he's a fantastic wife, Susan.
They have 4 children and 9 grandchildren.
And during that time, it's playing with them, he gets to do some woodworking.
So welcome to the presentation, Doctor Walters.
Thank you so much for Doctor Cassello.
I really appreciate the opportunity to be here today.
Great.
Thank you so much.
I'll let you go ahead and get started.
I'm a tune off and and, again, any questions you all have, put them in the q and a, and we'll get to those at the end of the presentation.
Okay.
So as far as disclosures here, I don't have anything to disclose.
I will tell you that I work as an expert witness on cases specific to sports medicine and offer a pin on, you know, failures of appropriate policies and procedures.
And I hope you'll see that this is a a lot of good information here today, and it's on best practices at current research.
You know, our our objectives here are primarily here to look at about cases.
Doctor Cassel was asked me to look at cases, you know, what went wrong, what happened, why did exertial heat problems happen, and then we wanna review some of the failures to prepare for better performances in the future.
You know, in legal cases, I think you have to consider what 12 people or 12 opinions, you know, jury box are gonna say.
You know, I'm gonna report on some cases today and how a jury response is often not one would anticipate.
You know, one of the big issues today that I think we have to think, and and guys, bear with me.
Sometimes when I start talking, I'll really get on some patents here.
But one of the things I think is really a concern today and things that people have to considers about professional liability.
When you're a state employee, many times you may fall under your State Tort Claims Act, and you have limits of liability.
However, if you're a contracted person or you're not an employee of a school or you're not a save employee, and you have professional liability insurance.
You're at the, you know, the liability as far as what coverages you have there.
So I think it's important for people to understand and consider what type of protection you have because I do think professional liability is importer.
Sometimes a state employee who purchases an additional policy and is at the at the institution may have extra liability just because they have insurance.
And so sometimes that can that can certainly be something he had to consider.
But I think he always has to remember opinions change and what we say today or the thought of today is subject to change.
You know, as research happens, as we discover in information within a case itself, you know, we'll we'll see things evolve through a case as we're going through there.
As as you consider that.
Some of the things I just wanna mention, 1st of all, is about standard of care.
And, you know, the standard of care is that level or type of care that a reasonably competent skilled health care professional with a similar background in the same medical community would have provided under these circumstances.
So these are things that are very often considered when you look at a case.
And then what is your scope of practice?
You know, that's what what are you qualified as a health care professional?
Are you deemed competent to perform and permitted to undertake and this often keeps the terms of your professional license.
So sometimes those will guide that.
So I think we have to look at this the the the scope of practice And what does our regulatory board tell us?
What do they what do they tell us that we can and we can't do?
And I think whenever people get outside of quote unquote their lane, that's where sometimes outside their scope, we can certainly have problems there.
Doctor Wachshund, one Doctor Wachshund, you're in If you would just make sure you have a single slide view.
I've had some couple questions from a couple of audience.
There I think you're showing presentation view, I believe.
You don't mind?
One second.
Sorry about that interrupting.
Let me see what's going on there.
And maybe just swapping over to Scott.
I'm probably sharing the wrong screen.
No.
It's okay.
Yep.
Better?
Yep.
That's it.
Great.
Thank you so much.
Sorry about that.
So, you know, whenever in a recent case, last just last spring, there was a case at the University of Oregon where a young man had a case of exertional red blood myelosis.
And my opinion there, I was hired by the plaintiff to opine on conditioning those types of things.
There were several other people that also provided an opinion there.
And I think that when we look at these cases here, we talk about bylaws and the NCAA bylaws, and the bylaws are from members and institutions to follow.
You know, there's probably 25 bylaws the NCAA has specific to health and safety.
The legitimacy of bylaws go as far as a level enforcement.
So if your institution does enforce that, it's gonna be a problem.
But then we have a lot of guidelines and recommendations, lots of recommendations.
And these are not enforced or required by the n c double a, whether it be CPR training for coaches, whether it be AED, Mercy actually has all these things.
These are not spelled out as a bible, and I think we have to remember that guidelines and recommendations They're only good is the moral compass of the people that implement them.
So if you're in a place, they should be part of your your your your practices there.
And so these guidelines and recommendations, and there's lots of lists of these.
There's lots of information here.
And I think guidelines and recommendations are definitely a dynamic forum here as a dynamic list.
It's gonna be changed.
We have to stay up to beat because these things are gonna certain certainly come about as we go to it.
It's gonna evolve here.
But I think we have to define best practices as it relates to our standard of care and the evidence.
And you have to look at this and follow these accepted treatment patterns and expected outcomes.
You know, I think we have to you know, all these tenets of care have to be addressed regardless of your location or your level of work.
As you look at this, you know, we have to have emergency action plans.
We have to have air rendered in a in a in a appropriately responsive time.
So and that's regardless of where we're working.
So I think there are gonna be changes.
There will be expectations that, you know, concussion care may be at a higher level at some institutions.
But the basics of care have to be provided for all those people.
And I think we have to remember that the same whether it be the the high school where my kids go to school, the athletic trainer that has the same license as a guy does that's working with professional football or professional basketball or the lady you're got applying applying care with the in WNBA.
So those standards are always gonna be there.
As you look at this case and I mentioned the stuff that's gonna go about the the the Douglas Brenner case, why did they go bad?
What happened here?
I think one of the the points that was pointed out in this case was the University of Oregon failed to supervise and validate strength and conditioning coaches ridicials and qualifications.
There's initial days at work in January 2017.
They directed a workout void of any condition the principles of progression, readiness, and appropriateness.
And we know the n c double a has an excellent term now that we we we coin called the transition phase.
And this will it it it it helps with this.
This has come out of the a couple of the documents that Doctor.
Casa presented as far as conditioning safety, and there's been several iterations of that now.
So I think this is a tremendous reminder for all of us.
But whenever we're working out athletes here and we're invoking multiple repetitions of the same exercise such as a push up, on the 1st day of workout, and then we felt this was excessive use of exercises, punishment.
And the university failed to monitor the the coaches relative to the utilization of a commonization principles.
They failed to see that new activity was introduced gradually and then accordance with accepted practices, and that, therefore, that transition phase was ignored.
You know, my concern was that the NCAA never investigates this incident or any other incident related to multiple cases of exercise induced rhabdomyolysis or the 30 plus deaths of student athletes secondary to exertional conditions.
So this is this is something that we found there that we just you just don't see this happening as far as the the appropriate reviews.
You know, I mentioned about he mentioned about the case that I've I've conducted at the University of Maryland, and then as you go back, you know, I would never release information or talk about a case, but when a case is public record, it's on the court or in the case of the of the Jordan Ear case, his the report is actually available online.
So if you wanna read my entire report, you can certainly do that.
But when you look at it here, the time from the onset of the persons that was working out here, this Jordan McNercid, The time from the onset of his cramps following his 7th repetition to being removed from the field was over 34 minutes.
So we know that whenever, you know, we're talking to it.
Whenever we have a person with exertional heaters, get them out of the sun, get them out of the heat, cool them down, and assess these people.
So we have to identify these problems.
We have to make sure that we're looking for these things to make sure that we go there.
The time, the interval from his cramps until his mental status changed was almost an hour later.
And so the 2 classic signs that I look for for exertional heat problems are number 1 of that mental status change and that elevated core temperature and what talk about that in just a second here.
Then the time from the old set of symptoms, for for the old set of centers until they called the 911 call was another hour 7 minutes.
And then the time from the 911 call to departing the fieldhouse was a 37 minutes.
So you see a lot of time here for a lot of treatment to be taking place here.
And the actual following the 7th repetition until they left for the hospital was an hour 39 minutes.
And doctor Casa and doctor, several studies have talked about this now, but that that 30 minutes that we have there, we identify with that 30 minutes that they present with those findings that they present with, whether it be mental status or they're starting to be lipidic or they're getting fatigue.
You're both we assess that court, and we recognize those signs of that additional heat problem, and we rapidly assess and we rapidly treat within 30 minutes.
You know, the the the doctor Casa said he's had over 274 cases now.
Of exertional heat stroke where these people have done well.
So there's something to be said about that 30 minutes in identifying that.
So what happened there, they failed to recognize the signs and symptoms.
They failed failed to appropriate treat exertional heat illness.
They didn't remove it from the radiant heat of the sun.
Didn't recognize assess or treat exertional heat stroke.
It was a total failure to emergency action plan, And if failure, the university planning specific to moving practices, the lack of emphasis on conditioning, colonization, and no respect a transition with conditioning test on the inaugural day of practice.
So they've been off for 29 days.
They came back to campus In that first day, they had a conditioning test of 10, 110 yard sprints.
And I think there's a lot of things that we're learning now about athletes.
We go train alignment the same way we train sprinters.
There's just no way we have to be very cognizant of the body habitus so that we train these people appropriately.
This next case was at Garden City, Kansas, a little bit different situation in the condition test again.
Was 36 forty yard sprints, but the you know, this it was questionable whether this athlete had been cleared yet medically.
He due to the area.
No acclimatization.
No conditioning.
You know, the the players were allowed to leave the field.
There was no supervision here.
And as you look at that, he conditions here and and does his test, and then He leaves the field.
He's upset with the team, and he just wanders off and goes back to his normatory.
He's found by players after a meeting.
And so they call the coach.
The coach runs over there.
He called and the assistant coach calls a head coach who says call the athletic trainer.
And then 7 or so minutes later, 11 minutes after he's found here.
Now EMS arrives after they are called, And, I mean, 20 minutes, they're treating him at the scene, never assessed signs or symptoms of exertional heat stroke.
Did not do anything to cool that person.
And within an hour 16 minutes, after they found this kid, he was dead.
Pronounced dead at the hospital.
So as you look at his 30 minute, his his comma went off a little earlier that they're So but they still when they got there, if they'd have seen that person, if they'd have called those people, they'd had a plan, we felt like that would have been a different outcome here.
Again, the failure of the principles conditioning acclimatization, there was also an altitude factor here, and there was no consideration for the transition concepts here.
Again, another condition test conducted on day 1, and I really think we're seeing this going away.
People understand that now.
As we're going through here.
There's also a failure to monitor weather conditions.
Do we have information specific to that venue specific emergency action plan and venue specific facilities.
You know, I'm not a fan of of web based data.
I wanna know what the WPGT is on that deal because the weather is gonna be dictated by the surface.
It can be dictated by the specific weather and cloud cover you have there, and I think that's very, very important.
There was also the failure to recognize, assess, or treat this case of exertional heat stroke.
Another case here is a soccer case that was in Division 2.
The institution failed to acquire and maintain appropriate necessary standard resources, heat stress indicator, ice ice machines, cold water rectal thermometers, before allowing athletes to begin assessments, conditioning, and training.
They didn't acclimatize the athletes.
There's a failure to accomatize and to implement appropriate plans to provide for progressive condition.
You know, they didn't have site specific emergency action plans, for each of the activities they were looking at here, and they failed to plan safe conditioning practices including the location, the timing and type of workout.
Now you schedule their their time runs at 2 o'clock in the afternoon, obviously, in this radiant heat of the sun on black top, asphalt in the heat of the day, on the very 1st day of pre season condition.
And again, they failed to recognize assess or treat appropriately on these these types of problems here.
Again, there was a there was a a softball player here that failed the emergency action plan.
They don't, you know, recognize the problems.
They don't assess the problems.
We don't have a plan, but we have to be looking for these things to make sure that we We recognize or we assess and we appropriate treat.
I do think there's something to be said about credentialing and privileges as as far as it just because your staff, I think we need to make sure that we're always training our staff.
Emergency action plans is not just why being an emergency action plan specific to exertional heat problems.
But it's also important that we train our people, that we educate them, we assess and that we continue to train.
And we make sure that people have the qualifications and they understand what they're doing here.
And I think the production and privilege process is so very, very important.
Now I just said they're a certified athletic trainer, but they understand they have the privacy of providing these services because they've been trained that way.
You know, in medicine, we were we we we give people privileges based upon their credentials, but they made sure those things are there.
They make sure they review that.
They make sure that that we have coverage, and we have protection here.
You know, the NCAA speaking on the college level and likewise a school level.
They have bylaws related to health care, but they are far from inclusive of the standards of care.
We have to make sure that we have appropriate recommendations and procedures.
You know, I'm always hear people talking about You know, I don't wanna put things in writing because then I'm held accountable to it.
To me, if you put it in writing, you're gonna practice it.
You can communicate it with your staff.
And you can make sure things are happening as you go back.
As we look at these cases here, what are some of the recurring themes that that have happened as you go back and look at all of these cases here.
And I think one of the things that the first thing that comes out is that it's you know, the the venue specific emergency action plan, do we have a coverage model?
The coverage model to me says who's providing what care and who's communicating, and how do we plan that, and how do we educate that, and how do we train that.
We have to go over these emergency acts plans to make sure.
If you have new staff, we have to go back and review that.
With that softball player, their emergency action plan is not to call the athletic trainer.
If an athlete is running into heat, they're exercising, and they collapse, you know, we've gotta provide basic first aid to that person.
If they collapse, get them out of the heat, cool that person down, and and and and activate EMS.
There was a 7 minute response time for the athletic trainer to get there.
They looked at him for 3 or 4 minutes, and then they decided to call EMS, and it had a 17 minute response time.
And nobody has assessed their core temperature yet.
And that way, if we see that, if we see that core temperature is elevated, we know that we need to have rapid cooling of that patient in cold water a 55 degrees as being circulated.
So I think we have to look at the emergency action, we have to have a plan.
Failing to plan is planning to fail.
What about vital signs?
Do we take vital signs?
This is something that we're really we're really pushing hard on today.
Is trending vital signs, blood pressure, pulse, or temperature, pulse oximetry, all of these things here that we can look at respiratory respiration rates, and we look at that, and that trending vital signs, you know, it helps us identify where that person is.
And if that core temperature goes from 102 to 104, we know that we're entering into an exert on each stroke, so we have to look at that.
You know?
But I think that's one thing that we've seen here.
There's another theme here as a failure of the bylaws in the collegiate setting.
Independent medical care, if we don't have independent medical care, or for using exercises, punishment, those you know, the bylaws have specifically addressed that now, and we have to look at them.
You know, the failure to implement appropriate training regimens, incorporating a commonization and transition periods, these have to be looked at.
We have to look at this year.
And just ignoring best practices for appropriate care, I think that's a thing that we certainly see.
So the colonization transition periods, you know, I think, you know, the the the in 2003, the Alloceas and NCAA guidelines were changed that we we didn't have as many 2 a days, and now we've gone completely away from 2 away 2 a days.
But all of these addressing the the the these these things about the practice times and the practice what they're doing here You know, I think we're still seeing a persistent rate of exertional heathrow fatalities because the focus is on the environment and the uniform as causes exertional knee strike, stroke.
While we ignored, as I said earlier, body habits and exertion.
So we have to look at this.
97% of the fatalities.
In this one study, send it the blind men had an average BMI of 36.
That's a different body mass index than the receivers have or the of the of the guy, the defense of backs who can run for dates.
What's interesting to note is since 2000 When Cory Stenger died, the NFL has had no deaths secondary to exertional heat stroke.
And I think my last tally, there are 32 plus collegiate guests and over 40 high school guests.
So the the problem is still there.
And I think the big reason is because we're focusing on the environment and the uniform as causes of the stroke and not looking at body habits, the exertion, and how we're training these people.
So we have to be understanding of this, we have to observe these areas and and and be cognizant of that.
I think we had to be objective.
We gotta validate.
We gotta document.
I mentioned about trending vital signs.
You have to know it when you see it.
You got I mean, when you see these signs, these these presentation, we have to be there.
I always worry about young athlete traders, fresh out of school.
When you get to that school and all of a sudden, that first day, that big lineman presents with you know, he's he's sweaty profusely.
He's getting busy.
You know?
And we know those can be signs of an early indicators of exertional heat units and possibly progressing into exertional heat stroke.
So we have to know it when we see it.
And we have to have the ability to pull those people, you know, and and and protect that athlete Everybody on the staff has to have on your team, on your health care team has to have a hand on that parachute cord.
They gotta be have the ability to pull that.
And I think we have to remember what are best practices, best practices are safe practices.
There are some awesome references here.
There's some awesome cases.
If you wanting more information.
I can certainly give you a list of articles here, but we have to erase these things because it's certainly is a major, major situation that we have to deal with today.
You know, one of the really good articles that I think has come out of this is the the Parsons Anderson Casa main line article preventing catastrophic injury and death and collegiate athletes.
And they talked about the problems with you know, the scientific principles of of of of of of of of of of conditioning, and they talked about the gradually and progressively encouraging the proper exercise and commoditization and the incorporation of the transition period.
We have to look at this.
You know, Casa has another article that talks about specifically the fact that conditioning how to prevent athletes' problems in conditioning.
And the the globalization conditioning is is 12.
The number 3 is talking about don't use, exercises, punishment.
But in this particular article here, we're talking about now the transition period.
And the acclimatization period has been increasing the collegiate setting.
The problem is that's for football.
But we still have basketball, cross country, basketball, baseball, soccer, that comes in, and from day 1, they start practicing twice a day.
Oh, they may scrimmage.
So we have to have that progressing that transition where we go from 50% to 75% to a 100% over the weeks here as we're doing that.
We have to be progressive.
We have to apply the science.
The science is there, and it certainly does a lot of things for us.
So let's talk a little bit about the scenario here with a summer workout.
You know, the athlete is struggling with making his times.
You know, he's had a history of this of struggling during workouts.
And being very dramatic.
And you go up to them and you see that they're breathing and heavy.
You know, they're they're cramping.
And then the coach yells at them and they do what.
They jump right up and get back in line.
And in between reps, you're seeing them getting some water, maybe wipe them down with a cold towel.
They're mildly unstable with running, but they're finishing and not stopping.
They're being very dramatic with the moaning and dropping on all fours and grasping grasping for air.
Now I say dramatic.
They may not be dramatic, but but they are presenting with them.
And then they jump back in line and continue to go.
And they continue to be encouraged to continue by the coaches that are there, the spring coaches, and and their position coaches.
And I think what we have to remember here is, how is this being perceived?
You know, what's happening here?
What's actually happening here?
If we see that person getting in trouble, I think they need to be pulled.
You know?
Obviously, I work in a in a pretty progressive and pretty aggressive setting in in college athletics.
And athletes were pushed, but I'm not saying everything I did was right.
But when I started to see a person change, Do I wish they'd have pulled Jordan McNair and I'll let him run those last 3 repetitions?
Absolutely.
Because we know that once they presented there, They may be overheating.
They're getting to that point where they're getting in trouble here as we go on here.
Again, the transition period showing both on a appropriate work to ratio.
And we have to look at that, you know, to make sure that we're letting these people have adequate recovery before they go on.
And if an athlete is in early season and they're having a lot of problem, I think their their rest of work ratio should be even greater.
And so we got to get them in shape we gotta get them conditioned.
They gotta be ready for that, and they've gotta go.
And I think if we're getting there, you know, I think we're finding out today that participation in the summer workouts on campuses under the supervision of the strength coach is preferable to an unsupervised workout elsewhere by unqualified individuals.
We're seeing today the support of having the strength and conditioning coach, but we're holding those people accountable to make sure they have appropriately devised workouts that we're going through here.
That these workouts are are approved by a credential strength and conditioning coach nozzle about the use of the colonization principles here.
And they're working closely with the medical staff, you know, as you look at that.
And and as you go through there, they're working with it.
And I'm not saying, there's a lot of concern about this that sometimes a medical staff may not know that much about conditioning, but they should know about the science, they should know about the basics here.
But we look at that and we I think we have to work together to make sure that we have a progressive plan that that that focuses on on getting better and progressively increasing at work as it going here on the and the elimination of exertion related activities, we have to certainly do that as we go through there.
So I go back to your scenario here.
My slide was out of order here, but when you look at this and that athlete that's jumping over there, And I think we have to look at that and and how do we make a judgment here?
How do we look at this and say, hey.
Based upon where they are, based upon what they're doing here, how are we gonna progress?
And I think as you look at that, you know, the serial postures of exertional collapse, and as we get there, we're scanning or our hands on our hips or we're leaning over or we go down to a knee.
But whenever that person is in distress here, you know, you know, versus fatigue.
You know, the signs of fatigue to me are not making their comms and moving slower Their hands are on their hips.
They can't run, but they can't walk.
You know?
And then when they get the stress here, that may be wobbly.
They may have panic demeanor.
They need assistance to be held up.
They can't answer questions.
And as I see them get to that distress point, I wanna make sure that I'm pulling them out of that activity.
I'm not letting that person continue.
Once they come out of that, they're done.
And I think this needs to be.
It's just like anything else, like your lightning plan.
It's any of your things that you're dealing with here.
You have you have a discussion with your coaches and you talk about that.
Now, I may be, you know, kind of the sky type thing.
You say, well, my gosh.
Good.
Then you're you're working on cases and giving opinions and those kind of things.
But I'm saying based upon what I'm reading today, this is what we need to look it.
Once you're done, you're done.
And I think COVID has certainly taught us a lot about how they'll progress, the fact that we're doing it, that utilizing that transition period now, and we're doing a lot more to try to be really effective as we're going through here.
So what are some of the things that we wanna monitor?
If I'm out there on the field here, what can I monitor?
And I think it and I talk about trending vital signs, I think these are are are ultimate importance here.
And I think a set of vital times, one set of vital times, signs may not be very good, but trending vital signs can be a tremendous help.
You know, when did the when did the issue start?
What time did it start?
And I talked about writing down vital signs, and I'm a share a document with you in a second.
But if you don't have anything, most of all of you have a phone or or a smartwatch now, and you can set your smartwatch where you can record, you know, conditions, you know, you've started to have cramping at 2:22 or whatever time it is because when you make that Record that scenario.
Your phone is gonna put a time code on that.
What's their respiration rate?
What's your pulse oximetry?
You know, we have these handheld pulse oximeters now, and they would tell us a lot about a person's condition.
Again, trending vital signs heart rate that they have postural tachycardia.
When we take a person from a line to a seated to a standing position with a 2 minute incremental there, what happens to their blood pressure?
Are they orthostatically stable?
What happens to their heart rate?
What happens to their blood pressure?
So we know that as we assess the person from an orthostatic, status.
We're gonna take them from lying flat down and check that blood pressure pulse and then put them in a seated position and they'll sit there for 2 minutes.
And then I'm gonna check their blood pressure and pulse, and I'm gonna look for that blood pressure to fall 20 millimeters of mercury on the systolic blood pressure or their heart rate clean, freeze 10 beats a minute.
That tells me they're not orthostatic, and then I would check them from a standing position.
And again, if your patient is dizzy, if they're dehydrated, they may have a base of bagel response here.
I mean, they may be unstable.
They're gonna fail that test.
So we wanna see, are they hosturally able to hold fluids here.
Are they are they orthostatically stable?
And that certainly is something we can look at.
And another great vital side here, as we said, is a core temperature as we look at that.
So, you know, there's there's lots of of equipment here today that we can look at here as as we look at the training vital signs here.
Some people talk about the rules of a 100.
You know, I really get concerned when the pulse is over a 100, when their temperature is over a 100.
And their systolic blood pressure is less than a 100.
That tells us we really need to be to me, it tells me I really need to be documenting this I need to look at this a little differently.
When that when that rules of a 100 takes place here, I wanna make sure then I'll look at that.
So the pulse is greater than a 100, the temperature is over a 100 degrees and or the systolic blood pressure has fallen under a 100.
Again, we're losing fluid.
We may be losing blood.
There's a lot of other things can be involved there, but we certainly have to be concerned about that as we go through and and allow that.
So some of the things.
The paradigm we've talked about, Doctor.
Bellville, you know, talks about the rapid recognition.
Looking for that, you're watching those athletes.
They start to stumble.
They start to get busy.
After the 7th repetition, they couldn't run by themselves.
They had to be carried or sweaty profusely.
They're labored breathing.
You know, get that person out of the heat, cool them down.
And if they're looking like they have a possible middle status change, or they're becoming lethargic, a rapid assessment involved the core temperature.
So we're going to use a thermistor here and and and look at that person's temperature.
And if it's above a 104 degrees, we know we need to cool that person down.
And we're gonna put them in a cold tub with that water being circulated around, we know that's the gold standard.
Many of you, I see the the people that are who are participating in this webinar today.
Many of you have been very involved in road races, and you've seen these cases of of heat stroke But again, rapid recognition, rapid assessment, rapid cooling, and then having a hospital identified that can handle this type of case so that we get those people there and they can handle that those types of cases.
So this is so very, very important.
And this Doctor Bell Bell's article is certainly a great reference here.
I will tell you I was involved in recently with some scenario reviews that we were teaching doing emergency spirits scenario reviews for the NFL and the and the NFL Players Association requires NFL teams to go through cases every year where they look at sudden cardiac arrest cases with, you know, major head and neck injuries truckal trauma, exertional heat stroke, and sudden cardiac arrest So as we're going through these cases and scenarios at at one venue up in Ohio and with this was actually with the USFL.
We were doing the same training for the USFL.
And we brought the people in, and we have a locally ambassador involved the athlete trainers are providing care, but we were running a scenario for exertional heat.
The athlete had a picture of a 107 The athletes approved the athlete trainers did a excellent job of identifying it.
They recognize that they assessed and they put the athlete in cooling, and the athlete was unconscious, and Glasgow Colmascale was at an 8.
And when EMS arrived after about 9 minutes, his temperature was still at a 108 degrees.
And so the EMS assessed, and they gave their trans transfer report.
And the EMS says, well, we need to take that athlete and get into the hospital.
And I didn't say anything.
I let them run scenario, ensuring that they take them out of the cold water, the transport.
So in the debrief, we were talking about it, and I said, why did you release that?
And they said, well, they said they were gonna take over.
And I asked the EMS about why were you taking a person whose temperature was still that elevated.
They said that's our protocol.
So it's a great time to have some good discussion, and we talked about the the prehospital care treatment of exertional heat stroke, which is an EMS documented Doctor Bill Bill wrote, and they've actually embraced that.
So this is a good thing that take to your EMS.
You can talk to them, and we told them why we wanna call first and transport second.
Because there's not a mechanism to cool at the hospital as effectively as the cold water.
And if we do that, we're gonna have much better outcomes.
So we had a good discussion.
And so, hopefully, now all those people in that area are gonna benefit from that training that they had that day where we looked at those cases because now we can see that we will have that the betterment of everybody.
So we have to talk about these protocols.
We have to understand that.
We have to share that information.
And make sure that everybody understands where we are.
You know, why is it so urgent?
Why is it why is it such an urgency for the treatment of exertional heatstroke?
And I think, you know, that either it's important that we don't waste time, substitute the invalid method of temperature assessment.
If rectal the long tree is not available.
We have to make sure that we look at those key diagnostic indicators, central nervous system dysfunction, you know, if they collapsed here and if we have that exertional heat shows expected is expected here, we're gonna certainly cool that person down.
You know, I think we have to look at that if we're if we're suspicious of exertional heat stroke.
We've gotta look at those signs associated there and make sure that include disorientation, confusion, business, loss of balance, staggering, irritability, irrational unusual behavior.
Half of the aggressiveness, hysteria, delirium collapse, loss of consciousness or even common.
And you many times don't hear people say that.
Athlete just had a change of character.
They cursed.
They did things.
They never done.
So when you see that, be be aware of that as the things that we have to be looking for.
You know, I think they may have a lucid interval.
But if it is an exertional heat stroke, the patient is going to curate fairly fairly quickly here.
So we have to look at this.
So what's the equipment I wanna have on board here I wanna have with me here.
I think this is a this is a a a a your doctor Jim Kyle's wanna talk to you.
This week.
This is what's on the back of my Friday night lights, my medic medical time out, but I have the missed report.
And so I'll get to that in just a second.
But you see all these items here that we wanna have in our exertional heat kit.
I think this is important to have Together, it's all right there.
You got your gloves.
You got scissors that you can cut your uniform off.
You got a the record to mister here.
You have a water based lubricant.
We have a duct tape.
We're gonna have our the mister market 10 centimeters.
So we wanna inserted that bar into the patient, into the rectum here.
I have duct tape for securing the the the the lead electro lead on their buttocks here.
I have a sheet, a a a twin sheet that I'm gonna roll up and use it under their arms to hold the patient back against the cold up.
So that way, if they start to go unconscious, I can hold them up.
I don't wanna hear.
I didn't we didn't put them in cold water because to be afraid they they would drown.
And that that's a poor excuse.
Have a plan.
You have to plan and prepare for that.
We have a pulse oximeter.
We have blood pressure, cussle.
We're monitoring vitals, respirations, part rate.
And, of course, I've got a notepad here.
But if you note here on the back of my mister Porter, the the the Friday night lights, the medical time out sheet, this is the flip side of my my sheet here.
And so as I look at it here, I've got heart rate, respiration, pulse ox, blood pressure, core temp in the Glasgow, Columbus field.
And I've got those doors across so we can look at that and see what their trending vital signs are.
Write them down.
You're not gonna remember that.
So make sure you write them down.
You can have somebody describe that.
And part of your emergency action plan may have a person identified to assist you with that, or you could use your phone.
There's lots of ways of doing this.
The missed report.
I mentioned about the missed report.
I think this is a hand off report.
You're gonna have a tremendous talk coming up in your program here from Adstrap.
Ad works with me a lot of times when we're doing the training here with the with the teams, but he talks about the transfer report.
He says many times as a paramedic, the athlete trainer comes up and they just start telling you about what's going on.
Give it to them in an organized way.
Most people that confront paramedics at a scene are not It's it's it's an alcohol related deal, and people come up to them.
They're yelling at them.
They don't know it.
They don't have any medical information.
But you need to present yourself as a medical person.
And the Mister Poors talks about number 1, telling them what the mechanism of injury.
You know, what's the name, age, sex of the athlete, the mechanism of injury, what's the medical onset, how long is it going on?
What's their history?
And then you give them the eye stands for the injury or illness.
You know what they have, deformity.
Pain.
That they have injury patterns, and then ask them for signs and symptoms.
And that's where you're gonna give your your your your treating vital signs.
And you give that information.
Your blood pressure was 120 over 80, and now it's down to, you know, 88 over 6 So, I mean, the blood pressure is obviously falling.
And then the treatment is what fluids, what medications, what response, what dressings, what splits, what you've done here.
As you're going through there.
So I think this is so very, very important, and it's another good thing for you to talk about.
So, you know, what criteria did you use for that athlete that was that was collapsing while I'm doing?
You know, from the outside looking in, The athlete was struggling.
They couldn't make their times.
They showed obvious signs of the stress.
People in the stands said, well, they were yelling at it yellow the kid to go on.
No one was there taking care of them.
So I really think it's important that we do a good job to identify these problems that we that we think about things from the other side of the of the table because sometimes what we let happen in sports is not always the best thing.
So you have a tough job.
You have a challenge, but we have to look at these things.
We have to be objective.
We have to implement care, and we have to provide protection.
As we're going through here.
That's what I have.
So if you have any questions here, Ray, I'd like to open that up if you could now.
Yeah.
Sure.
We have some fantastic questions here.
So I'm a go right to him.
We've got a couple minutes left, and we'll try to get to all these, like, five questions.
So the first one is from Ben Velasquez and question is, what is the discipline?
What was the discipline to individuals at Maryland and Garden City?
There was no disciplinary action on those things.
And I know we'll talk about personnel issues, but, I mean, you can read the deal.
There was no
Yeah.
Okay.
Heather is over in Cypress Lakes High School over in Houston.
And the question she has is do you do you do you have a a, I guess, a where is the validity or usefulness of weight charts for single practices.
I know it was come common practice for 2 a days, but since those are becoming a thing of the past, are they still relevant for entire teams?
Heather, that's a great that's a great question.
You know, I think that number 1, I'm a big fan of Wade George.
I really believe that we did a pre practice weight, a post practice weight.
And even as the 2 of days started to to phase out, you know, we would want a person to be within 4% of their pre practice weight before they ever left.
We always found that dehydration was a major problem.
And if you got dehydrated, we're gonna have problems later on.
And so before they could practice the next practice, they had to be with 2% of their pre practice weight.
So let's just take those numbers.
If a if a player weight, £200, 4% of it, he had to be at 192.
Before he could leave after practice, and he had to be at 196 before the next day's practice.
So the point is we didn't let him get dehydrated.
But was it a day to day weight.
That weight was held for the whole week.
So we applied that 2%, 4% to the whole to his weight or her weight for the whole week.
I do think there's a lot of of usefulness in weight charts if we could prevent dehydration at a major, major, major, major first step.
Excellent question.
Thank you.
Great.
Thank you, Heather.
Next question is from Dave Sillan.
And the question is, with your rules of 100, are you looking for all three pulse, temp, and systolic blood pressure to be at a 100 before detailed documentation of only one of the 3?
Great question, David.
I have to look at any one of the 3.
If I have any one of the 3, I mean, that just tells me I need to do more vital sign assessment.
That's kinda like my trigger.
That opens the gate just to start documenting.
I wasn't smart enough to come up with that, and that's obviously talked about a fair amount in the literature, but I think anytime that we have any one of those 3 that tells us we got enough stuff here that we need to be looking at.
Thank you.
I think to add to that, Doctor Walters, just for and for the audience, is anytime that something that raises to the level of suspicion, just as you're going through, you're gonna document it anyway, and it just starts the process for the trending data if you need to.
Excellent.
So I believe Sean Bolen is do you have any legal reservations about obtaining a rectal temperature on a middle or high school athlete?
I do not, and I think that you need to make sure you have understanding of the school.
I mean, they need to understand what you're doing.
But they your your school also needs to understand, this is a standard of care.
This is what's expected.
This is what they're gonna testify on the other side of that trial.
So this is what should have happened.
So I hear this all the time.
It's amazing to me.
Once that we made the Maryland report and we showed what happened there, how many people that were pushing back against retoprobes are now all over it.
I mean, they're you know, you you couldn't I mean, it's it's a definite change of of venue there.
I think to add to that, if you don't mind me adding 2 things I wanted just to make sure that, you know, look at all your state practice acts.
Because there are several states that may have something regarding treating minors, especially with a rectal thermometer.
And they have heard of 2 states, I believe, that have something along those lines.
And then the other one is to one of our upcoming speakers is David Fleishman, who's an attorney, who's gonna talk about what is the That's gonna be I think on think on Thursday, I've been on Wednesday, I've been on Thursday.
That's he's not focused specifically on what's the organization's responsibility in establishing a scope of practice for emergency care, for coaches, and healthcare providers.
I think, hopefully, that's gonna answer some of these questions or drive some other ones.
Ray, I'm really impressed with this this Siri.
You started off with a pretty weak call today, but I think you have really got some impressive people on this Again, and I'm I'm this is really good.
I really appreciate the opportunity to be here today.
Great.
Thank you.
And hopefully, the we'll continue the big thing is helping the conversations with that.
Moving on, Mario has another it's excellent question about wet bulb globe thermometers, and he or is asking best what's the best device Or what's the
I don't think there is a best advice.
The best advice is the one that you're using to get valid w b GT.
Now there's a lot of commercial devices out there.
They're very, very nice.
Some of them have gotten very, very pricey.
But I think you just need to make sure it's a device that is that that's valid.
I mean, that it's you know, there's gonna be some knock off devices.
There's some very expensive devices out there.
But, you know, there's a very popular one that that a lot of people are utilizing today.
So I think it's the biggest thing is it's gotta be valid.
It's gotta be a valid device.
And you gotta have a good protocol to to look at your numbers.
You know, if you you got a WPGT of of of 88, what's your plan?
You know?
Are you going you know?
So you just gotta, again, communicate with your coaches about this is what we're we're gonna use this to monitor.
Many of your states.
Now your state practice act are incorporating the WPG team.
One of my biggest headaches with WBT is the fact that the the evening mucus come on and talk about the heat index is a 107.
You know, how they measure their heat index, I'm not sure.
It sure never went with anything that we did as far as temperature, relative humidity or WPGT, but this is a great measure here, and that's you're you're in good shape if you're measuring that.
Great.
Thank you for that question and response.
Paul Osterman, his question is, how do we go about changing the culture of sports in sports.
We're all too often from a training perspective.
It's thought more is better.
O'Reast Industries continue to be a concern from the youth athletic all the way up to college at folks?
Paul, that's a great question.
You know, I think that I was watching a baseball game recently, and they were talking about 2 pitchers for an SCC team, and the players were gonna be out for the next 10 days ago because they had, quote, unquote, dead arms.
And we know that the announcer started talking about it all this training, all this stuff they're doing year round now.
They don't, you know, they don't ever have any time off.
And I think they're I think that's part of the problem from that perspective on the overuse.
But I think we have to have recovery.
We have to have time off.
We have to have I think one of the greatest things that's come out of the of all these these studies nowadays is this stuff about the the transition period.
And so we're identifying that.
That's not so much an overuse situation, but it does address the conditioning, the climate when you used to talk about conditioning, this climateization, now we're looking at the transition to progress these people as they're going through there.
I think we have to look it over you.
So I think we've gotta we gotta be smart about that.
You know, one of the things that with helmets and and concussion, we found out that we were doing all this hitting and practice, and the problem was most of the hitting was taking place when.
During the preseason.
So now we carry that dead or that load of all that trauma all sees alone.
So I think we're practicing better.
I think we're practicing smarter.
You know, I went from 2 football coaches.
I went from Bluehost to Steve Spurrier.
Blue holster was probably he was squeamaged every day for 2 hours if we could, and Spurs would have practiced in basketball uniforms if we could.
Mean, it's just a total mentality chain, different just different cultural approaches to it.
We're finding out today that when we don't hit so much.
We're not having near as much trauma and problems with the head.
So I think there's a lot of, you know, things to look at there.
Great question, Paul.
If you don't mind, we're gonna have one last question.
We may go men or so over.
That's okay.
Would you to Walter's to answer once again.
Okay.
Great.
So we have once pulled from a training session, is there any is there a suggested progression back into training for the following session.
Example, quote on Monday, what does their reentry to practice conditioning for the rest of the week look like?
You guys have some some really good question.
I think that's a I think I yeah.
I'm just gonna assess that person.
I'm evaluating them and see how they are.
And and and see, you know, if they're having if they're symptomatic the next day, we'll look at it.
I think I would definitely have a They would be on my alert group.
I'm gonna, you know, be watching those people just to see where they are.
You know, I used to have a card at every practice that had all the medical alerts on there.
You know, who was sickle cell a positive?
Who was allergic to bee stings?
Who had drug allergies?
Whatever.
And then if I had people that were in a condition concern, I would have those listed also, but I also told the street coaches that I wanna keep an eye on these people.
And it says in an island to beat them up and make them worse.
I wanna make sure because I think if we, you know, if we let those people come back and and we can wrestle them, That's certainly something.
We may need to modify their practice.
They may need to we need to, you know, limit their repetitions because we know if we have good work, we can get better If we overtrained, we're gonna tear them down, and I think we have to look at that.
There's so many metrics today that we're measuring, especially in in some of these collegiate professional programs.
We don't all have the luxury of having that.
But at the same time, I do think those are some things that we have to consider.
As we're going through.
Great.
Well, I think that about thank you, Doctor Walters, for answering those questions.
Thank you for the audience.
It's fantastic questions.
It definitely drives the conversation more in terms of improving health and safety.
For those of you who are still on the line, if you would, You wanna take a minute and throw any other questions out there, we'll definitely get back to you to make sure those questions are answered.
If you didn't answer them right now, In closing, thank you for session 1.
What a great way to pick start off the symposium for the for this next week.
And for everyone else, the this will be work it's being recorded.
We're gonna transition that to a CEU course.
We'll notify I'll notify you in within the in the week when those will be available.
This course will be available for their own demand access, and you can watch this those you purchased already.
You can purchase you can have the access at any time for BOC credit, and and they're not just viewing the course as a great review.
Doctor Walters, thank you again.
Pleasure to be have you on the session today and look forward to future converse conversations with you.
Thank you so much, and great job on this, Frank.
Y'all have a good day.
Thank you so much.
Everyone, we'll see you at the next session.
Have a great one.
Exertional Heat Illnesses Gone Wrong: Case Failure Points
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Updated Jan 22, 2024
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