Heat stroke, air quality prompt concerns for athlete safety

As athletes across the country begin preseason training amid the hottest summer on record, experts on heat-related illness say they are concerned that resources to keep sports safe, especially for younger athletes, are not keeping pace with hotter temperatures.

Douglas Casa, CEO of the Korey Stringer Institute based at the University of Connecticut, said his phone has been flooded with calls in the past week as this summer's historical heat wave begins to crash into the start of the oncoming sports season. An expert on heat illness in athletes, Casa said he is encouraged by rising awareness, but remains deeply concerned that the resources to keep young athletes safe are not keeping pace with the steady occurrence of extreme heat.

July marked the hottest month in Earth's recorded history, with roughly 100 million Americans in 20 states under heat alerts at the end of the month. The first few days of August have brought little respite, with some 65 million people in the South under heat alerts. Temperatures in Phoenix topped 110 degrees for a record 31 straight days, straining the ability of area hospitals to care for patients. Water in Florida's Manatee Bay climbed past 100 degrees and threatened world records late last month, endangering sea life along the coast. From Southern California to Caribou, Maine, record-setting high temperatures have made their way through a laundry list of cities this summer.

Casa and his team of researchers have visited more than 30 states in the past five years to advocate for stronger regulations for preventing and treating heat illness in high school sports. Since it opened in 2010, Casa has led the institute, which is named in memory of Korey Stringer, an NFL lineman who died of complications from heat stroke at Minnesota Vikings preseason training camp in 2001.

Professional leagues and colleges with sufficient resources have made considerable strides to combat heat illness over the past decade, Casa said, but he remains concerned that millions of young athletes in the U.S. aren't protected by emergency heat plans that could keep them out of danger. He said some states are still stuck "in the dark ages" with their planning.

"I don't think the policies will keep up with the dramatic changes that we're seeing," Casa told ESPN. "I just don't think they're going to keep pace with them because it takes so long to change health and safety policies, especially in high school sports... high school sports are [the] freaking Wild West."

Heat stroke is the third-most common cause of sudden death among high school athletes behind cardiac arrest and traumatic brain injuries. Sixty-seven high school athletes have died from exertional heat illness since 1982, according to the National Center for Catastrophic Sport Injury Research. Most of those deaths (52%) happened in August during the opening weeks of fall sports seasons, and the overwhelming majority of them (94%) were football linemen. All heat-related deaths, according to Casa, are entirely preventable with the right planning and minimal resources in place.

Treating exertional heat illness and heat stroke is a relatively simple process if someone identifies the symptoms early. The most effective tool is placing an overheated athlete into a cold immersion tub to bring their core temperature back to a normal rate. Cold immersion tubs -- most commonly a large rubber trough that can be purchased at hardware stores or farm supply companies -- cost less than $200. Dropping an athlete's temperature before trying to move them to a hospital or any other location is a vital step in effectively treating heat illness, according to Kathy Dieringer, president of the National Athletic Trainers' Association.

"Early recognition is critical," Dieringer said. "And having that [athletic trainer] at practice to note an athlete who seems to be struggling and then getting them in that cold water immersion quickly and for the appropriate length of time, that could be the difference between that athlete surviving or surviving without any kind of physical limitations."

In many cases, though, athletic trainers aren't present on the sideline of every school practice. Dieringer said only 37% of high schools have a full-time athletic trainer, and roughly a third of high schools have no athletic trainer at all. In other situations, athletic trainers are assigned to cover several different schools and are often stretched thin while trying to monitor many athletes across a variety of sports.

Erin Foreman has worked as an athletic trainer in northern Indiana for 17 years. She said she has noticed more interest in the training she does with athletes and coaches on heat illness in recent years. She is assigned to just one school -- Elkhart High -- and feels fortunate to have the resources she needs to be prepared to help athletes.

"There are some schools that don't even have athletic trainers to manage a heat station," Foreman said. "We do have those resources. I think it's probably hit or miss depending on if there's an athletic trainer available to the high school or not."

Foreman said that in August and early September, she arrives at football practices at least an hour early to set up a cold tub and a canopy for shade. She said being prepared is her most important tool in combating the growing risk of heat.

Researchers say having an emergency action plan in place is another crucial step to treating heat-related illness, but not as common as they would hope even among schools that have athletic trainers. A survey completed in 2021 found that nearly 30% of high school athletic trainers said they did not have a written plan in place for what they and other members of the athletic department should do in the event of a heat stroke incident.

"We have so much data that shows us heat stroke is going to happen. Knowing that means we have an opportunity to plan for it," said Samantha Scarneo-Miller, an assistant professor at West Virginia who conducted the survey. "Without putting pen to paper, so to speak, you are not being deliberate in your ability to think through all the different scenarios you might encounter."

Scarneo-Miller and Casa agree that strong laws or policies written by state high school athletic associations can drive more athletic trainers and others at schools to be prepared.

The standards for how high school teams prepare to treat life-threatening injuries are determined in some cases by state law, but more commonly by policies written by a state's high school athletic association. No federal laws govern heat policy for high school sports. A pair of Congressmen from Maryland have introduced a bill in honor of Terps lineman Jordan McNair, who died after suffering a heat stroke at practice in 2018, but requirements in that law would apply only at the college level. No national organization sets rules for high schools like the NCAA does at the collegiate level. The National Federation of State High School Sports Associations publishes recommendations for best practices, but is not in a position to require any schools follow them.

Researchers at the Korey Stringer Institute have graded all 50 states and Washington, D.C., on a 0-100 scale based on how many best practices are mandated by their policies. Fewer than half scored a 50 or higher in their most recent grades updated earlier this year. Still, those scores are a marked improvement from 2017 when researchers first started tracking state policies. Casa said rising temperatures and awareness of the issues have been a factor in the improving numbers, but historically, the biggest driver of change has been tragedy.

"The states often set the policies after they have the kids die," Casa said.

In Florida, a 16-year-old football player, Zach Martin, died in 2017 weeks after he suffered heat stroke and was rushed to the hospital rather than going into a cold tub immediately. Three years later, the state passed a law requiring all schools to have cold tubs and defibrillators available at all sports practices. It also requires training to teach coaches and athletic trainers to "cool first, transport second." Florida now ranks first in the Korey Stringer Institute's grading system, with a score of 86.04. New Jersey, Georgia and Louisiana, which have all recently improved their heat policies, are next in line.

Researchers say steady rising temperatures will make some heat illness incidents unavoidable in the future. Other impacts from the changing climate, such as an increase in wildfires like the ones burning in Canada this summer, also likely will have an impact on athletes.

Dr. Panagis Galiatsatos, a pulmonologist and professor at Johns Hopkins who has studied the impact of poor air quality on athletes, said breathing polluted air can have both short- and long-term negative effects.

"When you breathe in noxious stimuli, they're going to have a toxic offense," Galiatsatos said. "A lot of these particles are so small that they get into the bloodstream and circulation. Depending on the athlete, they may have a vulnerability that could lead to cardiac arrest, something we've witnessed in a few players in the last few years."

Even if the heat is manageable, air quality from wildfires and unpredictable weather can still cause issues for athletes.

Galiatsatos and Casa said they expect air quality and heat to continue to impact the timing of practices and games. Galiatsatos said he could see a future with far fewer afternoon baseball games or early-season noon college kickoffs. This summer, MLS postponed two matches in Austin to keep players and fans safe during hot days in July.

Casa said most heat issues occur in August when players have not yet had a chance to acclimate at the start of training camps. He said the safest move might be rethinking the timing of full seasons for a sport like football.

"I'm telling you, 15 or 20 years from now, football is going to be a spring sport," Casa said. "We're not gonna get people out on August 1, the hottest time of the year in America, the most humid time, in full gear with 300-pound linemen training in the worst conditions possible. ... If I started this all over again 100 years ago, I would've had football as a spring sport and baseball be the fall sport."

Casa said it has been encouraging to see states in the hot, humid Southeast adopt more comprehensive policies or laws in recent years. He said 20 of the 31 states his team has visited in the past several years have made "decent overhauls" to their heat policies.

Still, he hopes for a time when his phone ringing off the hook in hot summer months is due more to proactive legislators than parents of athletes who have suffered major consequences from the heat.