In Heat, Identifying Sickle Cell Could Be Live-Saving Discovery

Editor's Note: This is the second part of a four-part series on heat-related deaths in college and high school football. The first part, investigating why such a primitive killer still claims lives in a high-tech era, ran yesterday. Check back Thursday at 3PM for the next installment on whether the law is doing enough to protect athletes.

It was August, 1996. Scott Anderson was in his first year as the University of Oklahoma's head athletic trainer when a football player began struggling on a grueling first day of conditioning. It was not a surprising sight under the circumstances, and Anderson and others believed the players' issues were heat-related.

They were wrong.

But, thankfully in this case, they were not dead wrong.
When the player didn't respond to treatment, he was hospitalized for testing and observation. After it was revealed the player had sickle cell trait, the case was reviewed and it was determined that the incident was tied to the trait and overexertion. The player recovered and continued his career.

"Our eyes were opened to the incidents and to the risks, and we realized our peers in sports medicine really were working from the same perspective we were," Anderson told FanHouse. "And as we looked at the literature and the textbooks and the general body of knowledge, it did not cover the topic of exertional sickling. Again, our peers really were ignorant as we were."

That certainly isn't the case today, especially at Oklahoma, which is considered a leader in sickle trait research and awareness.

Anderson and Dr. Randy Eichner, Oklahoma's team internist, served as co-chairs of an inter-association task force convened by the National Athletic Trainers' Association (NATA) two years ago to confront the issue of sickle cell trait in athletes. In 2007, the NATA released a consensus statement to help peers reduce the risk of collapse due to the trait.

"Historically, there has been a lack of understanding for the risks and a lack of recognition for the occurrences," said Anderson, 52, a veteran trainer and graduate of Oklahoma.

Sickle-cell trait is an inherited condition that occurs in approximately eight percent (one in 12) of the country's African-American population. It affects the protein in red blood cells that carries oxygen to the body's tissue and organs. The trait can go from dormant and harmless to active and potentially fatal under extreme stress such as intense workouts, heat and dehydration.

The sickle hemoglobin can cause red blood cells to change from a circular shape to the quarter-moon sickle shape, leading to a "logjam" in blood vessels that can cause an athlete to collapse. This process can begin in as little as two to three minutes of all-out exertion.

Intense exertion in an athlete with sickle cell trait is thought to be the leading cause of death among NCAA football players during the past decade.

Seven of 19 non-trauma deaths among college players over that span have been tied to sickle cell, according to NCAA committee studying the issue. Other causes of death were cardiac related (six), exertional heat stroke (five) and asthma (one). Deaths tied to sickle cell prompted medical experts to emphasize the best treatment options for athletes who carry the trait.

Just as importantly, however, it must be stressed that the trait does not limit athletic participation.

"Athletes with this condition can succeed and succeed at the highest levels -- it has been proven over and over again by a number of individuals," Anderson said.

"But there does need to be some knowledge and that knowledge comes through screening. And, with screening, there can be education and precautions instituted and again it allows for those athletes to have safe participation in sport."



All 50 states and the District of Columbia screen for the sickle-cell condition at birth, but in many cases families aren't told the results, or they forget or ignore them.

The NCAA, which regulates college athletics, in June agreed to recommend that all of its schools confirm sickle cell trait status in all athletes as part of a legal settlement with the family of a Rice University player who died during a conditioning workout in 2006.

Testing indicated that Dale Lloyd's status as a carrier of the sickle cell trait contributed to his death. The lawsuit alleged that Lloyd's death could have been prevented had Rice tested for sickle cell trait and the NCAA mandated it.

The NCAA's recommendation for testing, however, is not mandatory and there is no data on how many schools perform screening. Less than a month after the death of football player Ja'Quayvin Smalls, Western Carolina has decided to test African-American athletes for the sickle cell trait. Smalls, 20, died July 8 after collapsing during a sprint workout. Cause of death has not been determined, although an autopsy was performed the day after he died.

Testing has been a constant at Oklahoma for more than a decade as part of the program's pre-participation physical evaluation, Anderson said. The screening for sickle cell trait is relatively inexpensive -- $3 to $5 for the initial screen, $30 to confirm a positive.

Anderson said screening at Oklahoma over the past decade has identified 19 football players with the sickle-cell trait. Of that number, two knew entering Oklahoma they carried the sickle-cell condition. However, in one of those cases, not even the parents knew the trait was present in their son.

Obviously, screening and notification are important. But additionally, acclimation during the first days of practice allows any sickle-cell trait athlete to compete normally. The NATA statement warned that "sickling can quickly increase to grave levels if the stricken athlete struggles on or is urged on by the coach."

That being said, Anderson said players must be prepared to advocate for themselves, informing trainers and coaches when they are showing symptoms that could be tied to sickle-cell trait. The bottom line hasn't changed, though. Education and precautions must continue to help all involved avoid any confusion regarding sickle cell trait.

Anderson learned that lesson firsthand.

"One of the problems and confusions -- just like our initial case that brought it to our attention -- we assumed that it was an exertional heat illness and that's a pretty common misconception," Anderson said.

"There's also a misconception that as you have sickle-cell trait you are predisposed to exertional heat illness and that is not the case. What needs to be understood is that environmental heat stress does create a risk complication for sickling. Whereas sickling doesn't predispose to heat stress, heat stress can create an additional risk for sickling.

"The insult for both of those injuries [exertional sickling and exertional heat stroke] is born in intensity. As there's a throttle on intensity, so to speak, and there's an appropriate progression of activity, that will help solve and settle both of those issues."