Lives in Peril as Temperatures Rise

This is the first part of a four-part series examining heat-related deaths in high school and college football. Check back each day at 3PM for the next installment.

Like any other collegiate football team, Western Carolina is in the process of preparing for the 2009 season. There are renewed expectations under second-year coach Dennis Wagner, whose team last year finished with three wins and snapped a 20-game Southern Conference losing skid. There is hope. There is excitement.

And, for the Catamounts, there is tragedy.

Ja'Quayvin Smalls was a seemingly healthy young man, at least until the early evening of July 8, when he collapsed on the field during a warm-up session for voluntary workouts and died later that night at a local hospital.

Observers said Smalls had complained of cramps at the beginning of sprint exercises and had been removed from the lineup to stretch. The workout was the first for Smalls, a junior defensive back who had enrolled in summer school after transferring from Georgia Military College.

"I think it's going to be something obviously that we never forget," Wagner said via conference call during the league's media day July 28.

"The young man made an impression on our team, our program, our staff through the recruiting process and being here for those four days. Any time a tragedy happens on the field the players are going to remember it. It's something they will never forget. I would say at this point it's more of our players concerned for Ja'Quayvin's family and how they are coping with it ... and trying to help them in any way we can to make this an easier situation for them."

The cause of death in the Smalls case is unknown, and it could take as long as three months before toxicology tests are back, according to medical personnel. While the temperature that day in Cullowhee, N.C., wasn't oppressively hot -- close to 70 degrees late in the afternoon -- the arrivals of camp and hot weather sends athletic training staffs at all levels into motion with a common concern:

Heat injuries in football remain a very real and serious problem.

The issue can be particularly worrisome in the Southeast, where the mix of heat and humidity are extremely high during the summer months. However, that's not to say this issue doesn't exist in cooler climates, simply because it's difficult to predict who will be affected and when because individual susceptibility varies.

As high school, college and professional practices begin in the summer heat, it has become especially important to take adequate steps to prepare and try to prevent heat-related issues.

"Many medical and training staffs go into the preseason worried about injuries. We are more worried about the heat - that's our No. 1 priority," Jack Marucci, director of athletic training at LSU, told FanHouse.

"Everyone is prepped and we do an orientation every year on how the process will happen, so it's not a crisis for us to see a player cramping or experiencing heat illness. Our staff will react quickly."

The heat is always on when it comes to one of nature's silent killers.

Heat-related issues, of course, are wide-ranging.

Preseason practice, 2008. The Miami Hurricanes are only in the first few days of camp under a brilliant, blazing Florida sun. Running backs Damien Berry and Lee Chambers each left a practice early after suffering from heat-related problems. The following day, running back Javarris James and defensive end Joe Joseph went to the sidelines with cramps.

"That's part of the game, especially down here," James said.

James is right. It is part of the game, albeit, a dangerous part if not careful or prepared. Due to the equipment and uniform needed in football, not to mention the daily dose of athlete machismo that surrounds the game, most heat problems have been associated with football.



While it might be difficult to fathom how players still die because of something that sounds as primitive as heat stroke, especially ranging from the technology of modern medicine to the simple gift of common sense, there's no denying this issue demands continued debate at various levels.

Expert Says Rate of Heat-Stroke Deaths 'Unacceptable'

Increases in football-related deaths because of heat stroke is one of the most concerning issues raised in the latest report published by the National Center for Catastrophic Sports Injury Research based at the University of North Carolina at Chapel Hill, N.C.

Dr. Frederick O. Mueller, a professor of exercise and sports science at UNC, wrote the report and examined "catastrophic injuries" -- defined as fatalities, non-fatalities with permanent severe functional disability, or serious injuries with no permanent functional disability -- in high school and college sports. Of 14 football-related indirect deaths in 2006 at the high school and college level, four were attributed to heat stroke, according to Mueller.

"During the past 10 years, there have been 25 heat-stroke deaths in football," Mueller writes. "This number is unacceptable since heat-stroke deaths are preventable with the proper precautions."

The American Orthopedic Society for Sports Medicine reports that 31 football players at all levels died from heat stroke from 1995-2008.

Minnesota Vikings offensive lineman Korey Stringer became the highest profile case when he died from heat stroke in 2001 during training camp. Stringer represented the first heatstroke death in NFL history.

That same year, incoming Florida freshman Eraste Autin died of complications related to heat stroke, six days after collapsing and falling into a coma following a July workout at Florida Field with teammates. Friends of the family said Autin had a major heart attack and that his body temperature rose to 108 degrees. It was 88 degrees with 72 percent humidity -- normal summertime weather for Florida -- the afternoon Autin collapsed while jogging back to the locker room.

Heat injuries can attack indoors, too.

In 2001, Florida State linebacker Devaughn Darling died during an off-season workout called "mat drills," where players quickly shuttle between stations that feature intense and timed exercises. Darling collapsed and died Feb. 26, 2001, of an apparent "cardiac arrhythmia" at the age of 18. On March 18, 2008, University of Central Florida football player Ereck Plancher first lifted weights for an hour and then collapsed after running sprints with teammates in the school's indoor facility.

High Schools, Colleges Step Up Safety Regulations

Organizations are rethinking approaches to conditioning and keeping athletes safe in the heat.

In Kentucky, high school football staffs must complete the new state-mandated, seven-chapter, four-hour online heat and safety course, which was the result of the heat-related death of a football player last summer in Louisville, before it can being preseason practice. While Kentucky's coaches say they are extremely cautious of weather safety in the summer, they also admit the new course heightens awareness of heat-related issues.

Additionally, Kentucky schools have already been operating under the state high school association's heat-index rule, which says that whenever the heat index (the combination of temperature and humidity) rises above 104 degrees, all outdoor practices must be stopped or canceled.

High schools in North Carolina are required to have a first-responder trained in cardiopulmonary resuscitation on hand during practices and games. They are also required to have nine days of practice before putting on pads or playing a scrimmage.

At Virginia Tech, the athletic department has a written policy for dealing with heat stress, which is included in a preseason book distributed by the football coaching staff to the players.

At Florida State in Tallahassee, Fla., where the average high temperature in August is 92 degrees and the heat index on the Seminoles' practice fields routinely exceed 100 degrees, veteran Director of Sports Medicine Randy Oravetz follows a detailed plan to help prevent heat injuries.

The top safeguards are acclimation and hydration. Players need to be in good physical condition to help adjust to the heat, and replenishing fluids and staying hydrated are extremely important, even if the Florida sun peeks behind a cloud in August -- or in December, for that matter. Players can dehydrate in any season, not just in hot weather.

According to medical experts, dehydration of just one to two percent of body weight (only 1.53 pounds for a 150-pound athlete) can negatively influence performance.

"We are trying to do all the right things and we continually check our training policies and procedures to make sure we are thoroughly prepared," said Oravetz, who supervises a staff of 10 assistant athletic trainers, five graduate assistants, and 42 curriculum athletic training students, many of whom rotate and help work football practice.

In addition to scheduled breaks, the Seminoles routinely take a knee five to six times for a minimum of one minute during practice, and it's mandatory players remove their helmets. One-hundred gallon water containers spread around the three practice fields are refilled two to three times, 50 to 60 gallons of Powerade is available to players, cold towels are handed out and a 2,000-pound ice bin is available for water immersion to rapidly cool players who are experiencing heat issues.

Once inside the locker room, additional fluids are available as are quick snacks (pretzels, peanuts, popcorn) that will provide immediate salt replacement. Players are also weighed before and after practice to help ensure their strength, stamina and safety. (A two-pound weight loss represents approximately one quart of fluid loss, according the the NCAA Sports Medicine Handbook).

There are several types of heat injuries.

First, and often unrecognized, is heat fatigue. It's categorized as a tired feeling associated with a drop in performance. It occurs most frequently early in the season before an athlete becomes acclimated. The second, and much more recognized problem associated with heat injuries, is heat cramps. Cramps are common and occur frequently in the calf muscles during practice or games. However, cramps may also occur in the evening at rest.

Heat exhaustion is a much more serious medical problem. It occurs as the body is unable to eliminate heat as fast as it is being produced. The symptoms typically include dizziness, nausea, headache, increased pulse, and disorientation. This can progress quickly to the life-threatening condition known as heat stroke. Therefore, early recognition and treatment is critical, according to FSU team physician Kris Stowers.

The most severe type of heat illness is heat stroke as it can result in death or permanent brain injury. This occurs with a rapid rise in body temperature to 105 or above and is a medical emergency. It can occur without having heat exhaustion or other forms of heat illness. The main difference between heat exhaustion and heat stroke is that there is neurological involvement, typically confusion that can lead to loss of consciousness, seizures, and severe disorientation.

Notre Dame practiced in high 90-degree weather with a heat index of 100 on Sunday. The Irish were not in pads yet, but players still were prepared for Mother Nature.

"In my career the transition to camp is always hot," said Chris Stewart, a 330-pound guard. "So, it's like welcome back football. You just have to realize that you have to hydrate a whole lot more. You have to be on top of your game, as far as hydration. Knowing what to wear, what not to wear."

Safety has also come in testing.

Sickle Cell Complications Have Caused at Least Seven Heat Deaths Since 2000

Sickle cell trait, an inherited blood disorder made more dangerous during strenuous exercise, is a major concern that has attracted increased attention. The sickle shape makes it hard for the cells to pass through blood vessels, which can lead to medical problems and death. One out of 12 African-Americans has the sickle cell gene, compared to anywhere from 1-in-2,000 to 1-in-10,000 Caucasians.

According to published reports, at least seven college football players -- including Darling at FSU and Plancher at UCF -- have died from complications related to sickle-cell trait since 2000. All seven deaths occurred during off-season or conditioning-related events.

The NCAA, which regulates college athletics, recently agreed to recommend that all of its schools require sickle cell testing as part of a legal settlement with the family of a Rice University player who died during a conditioning workout in 2006. The testing, however, is not mandatory.

In most cases, the treatment of heat illness, which focuses on rapid cooling, usually starts with the trainers.

Oravetz and Marucci agree that the relationship between the coaching and training staffs is important. Moving practices indoors because of extreme heat or pulling a player from the field due to heat-related issues are critical decisions, especially in preseason camp when teams have a limited amount of time under NCAA rules to prepare their season openers.

"You have to feel comfortable with your coaches and they give you enough leeway if we have to pull a kid off, because there's always that notion to say he's too soft," Marucci said.

"There's always that fine line. That's football. It's not always an easy call but we've seen enough of these things that the coaches trust us and there's not much of an argument if we have to remove a player from practice."

There are times, however, when a team might opt to take advantage of warm weather. That was the case on Sunday in Morgantown, W.V., where temperatures reached the mid- to high-80s and West Virginia coach Bill Stewart lengthened practice by two periods. "The heat," Stewart said, "was a great asset to us. We could play a lot of games in this kind of weather."

Stewart's staff, as always, took a cautious approach. It also proved to be a good call by Stewart -- it was 74 degrees in Morgantown at 5PM Monday.

Preventative Steps

While it's agreed that common sense and a cautionary approach to practice and games will almost always prevent medical problems, Mueller writes in his report that he suspects any or a combination of three factors could be leading to the increased fatality rate in football from heat-related issues:

* The prevalence of over-the-counter drugs and supplements, such as products containing ephedra and the lack of understanding by coaches, parents, and athletes of the physiological effects of such supplements. Since supplements containing ephedra speed up the body's metabolic rate, they counteract the body's ability to shed heat.

* Coaches and trainers not following preventative recommendations that have been successful in the past. Mueller contends that the dip in heat deaths in the 1980s and 1990s accompanied the successful preventative measures, but says it's possible these efforts have subsided.

* Players not being properly acclimated to and conditioned for exercise in the heat.

In 2003, the NCAA Management Council made a sweeping change in the traditional approach to fall camp from information gathered from sources regarding conditioning, heat acclimatization, dehydration/re-hydration and recovering from high-level activity and fatigue.

The change called for the first five days of preseason practice to be limited to single practices, with gradual increase in equipment from shorts and helmets to half-pads to full gear. The practice format after that will allow for a 2-1-2-1 framework, eliminating consecutive days of multiple practices. In 2001-02, the NCAA said that 91-percent of all fall heat illness was reported from football.

At WCU, Wagner's team will head into the start of practice with Smalls' memory in its heart.

Wagner said his staff and players have been dealing with the death by having meetings, making counselors available and keeping the communication lines open. For the upcoming season, the team plans to wear "JS" decals on the back of every helmet in memory of Smalls. His locker inside the Dale and Dianne Hollifield Locker Room in the Ramsey Center will not be reassigned and will be memorialized to include his helmet, uniform and any additional game-day equipment.

In addition, there also will be a one-year moratorium on the use of the No. 3 jersey that would have been worn by Smalls.

Players were running sprints in the school's football stadium when Smalls complained of cramps and left the drill to stretch. While on the sidelines he quit breathing and team trainers administered CPR before transferring him to a hospital in Sylva, N.C., where he was pronounced dead.

Tragedy also struck July 29, when a 16-year-old Fort Campbell High School football player who collapsed on the field during a morning practice in Nashville, Tenn., died.

Timothy Williams, who according to his coach became "lethargic" after a morning workout on Tuesday, died the following day at Monroe Carell Jr. Children's Hospital at Vanderbilt University. Authorities have not determined the cause of Williams' death. Highs on that Tuesday reached the mid-70s.

Even when every step and precaution are taken to help help prevent a tragedy -- under any circumstances -- Marucci stressed that constant surveillance and education are necessary when it comes to dealing with heat-related problems.

"The health of our athletes is our top priority and we continually re-educate ourselves regarding heat-related issues," Marucci said. "You are getting into a recipe for trouble if everyone, from staff to coaches to players, are not prepared."