That’s right, I believe the real problem is much deeper seated.  There is a growing concern today for the number of deaths taking place in non-football related activities.  Football players – especially in the Football Bowl Subdivision, are being driven harder and harder today.

Scott Anderson, a past-president of the College Athletic Trainers Society (CATS) sounded the alarm in college athletics in January 2011 with his comment to senior writer Dennis Dodd on CBSSports.com.  “The way we’re training college football players in this day and age is putting them at risk,” Anderson said.  “Twenty-one dead football players and we’re still today training them the same way as we did dating back to at least January, February of 2000.”

Is conditioning the problem, or is something else going on?  Several years ago, we were alarmed from the incidence of sudden cardiac death, as related to those student-athletes falling out with no reported medical history of cardiac issues.

One underlying principle athletic trainers must deal with today is the concept of “care” versus “coverage.” Care involves a hands-on, comprehensive service including the prevention, care, and rehabilitation of athletic injuries.  Care is what we have tried to provide for years.  However, today administrators are more interested in having coverage as this is much less expensive and requires less institutional commitment.  Health care providers need to fight for care, and administrators with any prudent understanding will embrace and support care over coverage.  The problem is, health care is not glitzy like shiny uniforms or JumboTron scoreboards or expansive facilities.

The first known case of sickle-cell trait causing a death at the NCAA level was discovered at Colorado in 1974.  More recently, Florida State player Devaughn Darling died in 2001 during “mat drills.”(Wikipedia, 2002) His family settled with Florida State for $2 million.  There remains disagreement about Darling’s cause of death, but both Devaughn and surviving brother Devard, who transferred from Florida State to Washington State after the death, were found to have the sickle-cell trait.  Also, there was Dale Lloyd II, who died a day after he collapsed during a conditioning workout in 2006 at Rice University.  Lloyd’s family requested in its suit settlement with Rice that the NCAA mandate member institutions to test for the sickle-cell condition.  The list continues . . . Central Florida’s University of Central Florida freshman student-athlete Eric Plancher died in March, 2008.  There was some question about whether adequate staffing was provided to Central Florida student-athletes.  Plancher was another in a line of student-athletes who have died from conditioning-related activities in Division I football.  The offseason workout was determined to have triggered his sickle cell trait.  The case received a great deal of attention.

Following Plancher’s death, the University of Central Florida commissioned a high-profile investigator, Michael Glazier, to review the Knights’ football athletic training practices, policies, etc.  The report compiled by Glazier (Glazier, 2009), a former NCAA investigator and attorney based in Kansas City, Missouri recommended that Central Florida improve communication between its athletic training staff and athletic department administrators, consider adding a fourth certified athletic trainer exclusively devoted to football, and enhance its nutrition education and support for players.  The report addressed staffing at Central Florida, and referenced like institutions in Division I.

The University of Central Florida eventually lost the $10 million dollar law suit.  Other colleges and universities are waiting their day in court including the University of Mississippi and Western Carolina University.

Sadly, I am not certain larger staffs equate to a higher quality of athletic training care.  The UCF report from Glazier specifically addressed staffing.  What we have today at many institutions is coverage with minimal or little health care being provided.  Why else would student-athletes with sickle cell trait be expiring in cases where the health care team knows the student-athlete is positive? There is a duty to educate the student-athlete, coach, strength coach, and to communicate all this to the student-athlete’s parents or guardians.

Any death is a concern, so the number of non-practice field deaths should alarm everyone.  Many of these deaths have been sickle-cell trait related.

As I visit with institutions and athletic trainers, the number of sickle-cell trait positive deaths concerns me.  There are identified steps to be taken for these cases and excellent education and information is provided by NATA, the American Medical Society for Sports Medicine, the American Orthopedic Society for Sports Medicine as well as other groups.  The NCAA also includes information, but I prefer to obtain my medical information from medical organizations, not a membership or sanctioning organization.

The education of the health care team and coaches over the recent years has certainly grown.  My fear and constant concern is with all the testing and education that is being mandated by the NCAA and other organizations – we still are having deaths to student-athletes known to be Sickle Cell Trait positive! The bottom line is we are not adhering to the guidelines which have been established.

Somewhere, somehow, something is wrong.  In my book Tape, I-C-E, and Sound Advice, I reflect on my twenty-seven year career in college athletics – reflecting on guiding principles and policies I was exposed to . . . and how they impacted the care of student-athletes.

You are probably as sick as I am of all the talk on concussions. What’s the genesis of the problem – is it the helmet, is it training and conditioning, is it the speed of the game . . . Just last week I saw where a player was penalized (college) by suspending him for a game seven days after a hit. Now I want to be clear, players should be penalized for what is deemed as a potentially catastrophic hit. But seven days later?

My thought, penalize the athlete, but severely penalize/punish the game official who did not make the call. The point is if we enforce the quick whistle, and the head-first contacts; this problem will resolve. Dr. Robert Cantu has eloquently said in many of his presentations that the helmet itself is not the problem. The problem is the linear acceleration and cummulative contact these athletes endure during practices and games.

Let’s see what we can do my enforcing the rules and taking the head out of football. Through time, the more protective the helmet has been, the greater the number of neck and associated head injuries as these players deems themselves indestructible. Officials have a significant responsibility, and need to take it seriously

during a game.
Today there is lots of emphasis on hydration with physically active patients. Now it’s water, water, water . . . you can’t get too much! The more . . . the better. Actually, you can get too much water, and a combination of electrolytes and water are best.

We know now that dehydration can contribute to heat exhaustion and even heat stroke. Fluids will protect the body from dehydrating, overheating, and cramping. In a given practice—one of our offensive or defensive linemen may lose up to 15 pounds of fluid. We require them to return to within 4% of their pre-practice weight prior to leaving the locker room—Athletic Trjaining Room area and return to within 2% prior to subsequent workouts! Thus, heat illness is prevented as the greatest way to have a heat related death would be to exercise in a dehydrated state.
It’s important to remember that thirst is not a good indicator of dehydration. In fact, when you feel thirsty . . . you’re probably already a quart low! That’s good information whether you’re an athlete or not . . . drink, drink, drink.
The National Athletic Trainers Association recommends that athletes take drink breaks at least every 45 minutes during practice and play . . . many coaches and athletic trainers demand even more frequent breaks. Drink selection needs to be less than 8% concentration of sugar in order to avoid a slow down in gastric emptying. Basically, no caffeinated drinks.
The night before the big game or event, athletes need to drink Gatorade to help the body store fluid and reduce the risk of dehydration the following day. Athletic Trainers and Physicians know they can prevent a lot of heat-related events by proper hydration. Once athletes understand and comprehend this, we are well on our way to preventing heat related illness. If we rely on our thirst as a guide for fluid replacement – we are way behind. Remember the guide for weight charts and effective prevention of dehydration of your patients. This plan helps prevents fluid loss and subsequent predisposing patient to heat related events.

Key Points
1. Prior to training camp, athletes should be encouraged to undergo strength training and aerobic conditioning to help them begin to acclimatize to warm weather.
2. Sweat rates in athletes such as football players can result in rates of fluid turnover in excess of 10 quarts (~ 10 liters) each day. Substantial losses of sodium and chloride in sweat require adequate fluid and mineral replacement during practice and at meals.
3. The risk of musculoskeletal injuries, heat illness, and upper-respiratory tract infections during training camp can be minimized with adequate rest, proper nutrition, and ample ingestion of fluids before, during, and after training.

Keeping plenty of replacement fluids like Gatorade available for players during breaks is vital to reducing incidents of heat related illness.
INTRODUCTION

Two-a-day practice sessions are often a part of early-season conditioning in American football and year-long training in many other sports. The extra practice time helps accelerate physical conditioning, allows time for strength training and skill development, and helps develop camaraderie among teammates. The very nature of two-a-day practices stresses survival of the fittest. Athletes are frequently placed under additional stress by the heat and humidity that often accompany summer practices. Our expert panel discusses the impact of the high-energy requirements, the limited recovery time, and the psychological stress of “making the cut” during two-a-day training. Strategies based on scientific theory and clinical experiences are presented to help athletes get the most out of two-a-days.
1. What amount of fluid loss can be expected in these athletes?
Walters: In my experience in the college setting, it is common for a football player to lose over 12 pounds during practice-even when we go to tremendous efforts to force fluids on these guys. Studies report as much as 24 pounds of fluid loss (about 11 kg) in a 24-hr period. Regarding fluids and electrolytes, we know these are vital to bodily functions. Players simply can’t practice effectively without proper levels. When the body’s fluid level drops, the body can not adequately cool itself or perform normal metabolic functions that support physical activity.
2. What strategies do you recommend to maintain energy intake and lean body mass during two-a-days?
Walters: During the two-a-day routine, athletes have to be diligent in maintaining hydration status. Furthermore, they must understand that losing body weight during practice comes from fluid, not fat! By maintaining proper hydration, we can prevent much of the problems associated with heat-related illnesses. We require athletes to weigh in before and after each practice-in their shorts only. During the first practice of each week, the athlete’s weight is recorded. From this, we determine the athlete can leave the training room and for allowing participation in subsequent practice sessions. After a practice, the players must attain a body weight within 4% of their “certified” weight before they can leave the training room. Before they can participate in the next session, their weight must be within 2% of the “certified” weight. We give our players Sundays off, and this day of rest allows them a chance to rehydrate-and establish a new weight to be certified on Monday.
3. What tips can you offer to athletes preparing for two-a-day sessions?
Walters: I don’t believe there is any replacement for athletes being in top shape. I see fewer injuries in those teams that are in good shape-and further, when injuries do occur, well-conditioned athletes seem to be able to return to play more quickly. Further, acclimatization, or being accustomed to the environment, has to be accomplished. Other ways we combat the risk of heat-related illness is with good nutritional habits. Maintaining fluid balance is also critical. We monitor pre- and post-practice weights and chart weight loss so that we can accurately advise athletes on their fluid intake. Finally, adequate rest must be accomplished. We try to work our athletes hard on the field, but make sure we give them time to rehydrate, cool down, and relax. We also make sure to have several hours of rest between practices to allow for adequate recuperation.

Getting Gatorade on the field and into the players during timeouts can give your players a competitive edge.
Here are some additional tips on ways to make two a day football practices, in the heat of the summer, safe and productive. These tips were provided through Gatorade’s Sports Science Series, a series that Dr. Walters was a big part of during his days working in college athletics.

Stay Cool
• Get in shape and acclimate.
• Know the warning signs of dehydration and heat illness.
• Don’t rely on thirst to drink.
• Drink on schedule.
• Favor sports drinks.
• Monitor body weight.
• Watch urine color and volume.
• Shun alcohol and caffeine.
• Key on meals.
• Stay cool when you can.
From: Eichner, E.R. (1998).
Treatment of Suspected Heat Illness.
Int. J. Sports Med. 19:S150-S153

Athletic Trainers have a crucial role in maintaining the hydration level of players in practice activities as well as on game day.
Stay Healthy
• Minimize the stresses of life.
• Eat a well-balanced diet.
• Avoid over-training.
• Sleep well.
• Avoid rapid weight loss.
• Avoid sick people and large crowds.
• Keep hands away from nose and mouth.
• Get a flu shot.
• Key on meals.
• Stay hydrated and ingest carbohydrates during exercise.
From: Niemen, D.C. (1998).
Immunity in Athletes: Current Issues
Sports Science Exchange 11(2): 1-6

Stay Hydrated
• Drink throughout the day (water, sports drinks, fruit juice, non-caffeinated soft drinks).
• Drink at least 16 oz. two hours before a practice or game (to allow time to urinate).
• Drink another 8 oz. 15 minutes before exercise (to help insure immediate hydration).
• Drink to fully replace sweat loss during exercise (at least 4 to 8 oz. every 15 minutes).
• Drink 24 oz. for every 1 lb. Of body weight deficit after exercise.
From: American College of Sports Medicine (1996).
Exercise and Fluid Replacement.
Med Sci. Sports Exercise 28(I): I-iiv.

The following post references the practices I recommended during my tenure as the Head Athletic Trainer at the University of South Carolina. The University is in the midst of the heat belt of southeastern United States, and aggressive strategies had to be embraced to keep our student-athletes safe.