With the start of football and the rest of the 2013-2014 school athletic calendar, districts are looking at new laws and training recommendations to help avoid deadly health problems among the 7.5 million students who will play high school sports this year.

Experts say that deaths from heat stroke and sudden cardiac arrest—the medical emergencies that most commonly kill students during athletic practice and events—are largely preventable. “Kids who participate in high school sports or at any level have the right to be in as safe an environment as we can provide,” says Jim Thornton, president of the National Athletic Trainers’ Association (NATA), which issued recommendations in June to prevent sudden death in secondary school athletes.

NATA offers guidelines on treating and preventing concussions, sudden cardiac arrest, and exertional heat stroke. It also recommends schools have emergency action plans (EAPs) that include the location of life-saving equipment, such as automated external defibrillators (AEDs). “If you don’t have an EAP for each venue, season, and sport, then you’re really behind the eight-ball. Nobody will know what to do,” says Douglas J. Casa, who chaired NATA’s task force on preventing sudden death. “Often the deaths that happen are completely preventable.”

Earlier this year, The Youth Sports Safety Alliance, created by NATA and composed of 112 organizations, launched the first-ever “National Action Plan for Sports Safety,” which recommends all schools have a comprehensive athletic health care program and a health care team. The alliance also released a student athlete “bill of rights,” which include 10 recommendations. One such tip is having access to safe playing surfaces and “immediate, on-site injury assessments” by sports medicine professionals.

The National Football League and National PTA will launch this fall the “Back to Sports” initiative to educate parents and community leaders on topics such as concussions and nutrition. And South Carolina is the 49th state with a youth concussion law.

Without a national governing body for high school sports, ensuring safety often rests with states. For example, every state but Mississippi has youth-concussion laws, many spelling out when and how students may return to play. New Jersey requires AEDs for athletic events and EAPs for sudden cardiac arrests. And Washington requires high school students be offered CPR instruction.

“We’re definitely headed toward more legislation if legislators don’t feel schools are taking appropriate measures,” says Judy Pulice, national manager for state legislative and regulatory affairs for NATA. “Nobody wants to do away with sports, and a lot can be done, and done inexpensively, to keep athletes safe.”

Before play

Most high school athletes get a physical before each season begins. There are no national standards for these exams, but as more student athletes suffer sudden cardiac arrest, experts have suggested including a resting EKG (electrocardiogram).

An EKG can detect heart muscle disease such as hypertrophic cardiomyopathy, which is a leading cause of death in young athletes, says Dr. Jonathan Drezner, immediate past-president of the American Medical Society for Sports Medicine (AMSSM).

The American Heart Association recommends EKGs, typically a $25 procedure, only when a physical shows a problem, such as a heart murmur. Drezner says that while offering EKGs would be ideal, it’s not feasible to screen every athlete in the country until there are enough doctors to interpret those tests.

“AEDs are where everyone needs to focus first,” says Drezner, a professor in the Department of Family Medicine at the University of Washington. “AEDs save lives, but they must be accessible, and not locked in an office or cabinet. If your school doesn’t have an AED, CPR-trained staff and emergency action plans, you’ve got to clean that up. In 2013, that is the standard of care.”

Drezner led a two-year study of more than 2,100 high schools and found the rate of student sudden cardiac arrest from August 2009 to July 2011 was 1 in 80,000 per year. More than 80 percent survived when treated with CPR and AEDs, which can cost as little as $700.

A decade ago, media reports reported that 1 in 200,000 high school athletes suffered sudden cardiac arrest, but that may be an underestimate, he says.

Both NATA and AMSSM recommend AEDs in schools. “Historically, schools—both K12 and higher ed—have been immune from liability under the concept of sovereign immunity,” says Pulice, the legislative expert at NATA. “That, however, is breaking down now, and we believe that as more states and more schools adopt various standards, those without them are extremely vulnerable legally.”

Heat stroke

Among the most preventable and treatable causes of death in high school athletes is heat stroke, often brought on by intense activity in hot conditions, says Casa, who also is chief operating officer of the Korey Stringer Institute, named for the Minnesota Vikings lineman who died in 2001 from heat stroke. The Institute is at the Neag School of Education at UConn.

“Heat-related incidents are 100 percent survivable if you rapidly cool the athlete,” says Casa.

Thirty-one high school football players died of heat stroke complications between 1995 and 2009, according to research at the University of North Carolina. In 2011, the latest year for statistics, six high school players died, Casa says.

Common signs of heat stroke include confusion, irrational behavior, and finally, collapsing. “You basically have 30 minutes to get the temperature under 104 to guarantee survival,” Casa says. “Cold water immersion is best. You also can use wet towels or douse them with cold water from a hose or locker room shower.”

Casa says to avoid heat stroke:

• Slowly get acclimated to the heat, by starting with shorter workouts and not using helmets or pads, then gradually increasing the duration and intensity of workouts and use of equipment;
• Be fit—get in shape before pushing even harder in the heat;
• Hydrate before, during and after typical workouts;
• Rest in shade and remove helmets or other equipment when resting;
• Use cold wet towels or mist.

Concussion tests

According to a 2011 study in the American Journal of Sports Medicine, high school athletes suffer 300,000 concussions a year. The number increased 16 percent a year from 1997-1998 to 2007-2008.

State legislative response to concussion statistics began in 2009 when Washington passed the first concussion-in-sports law, which requires students suspected of having a concussion be removed from competition and have written clearance from a healthcare provider before returning to play.

The Centers for Disease Control’s “Heads Up” program offers free videos, online training, and other information about concussions.

“The first line is education, vigilance, and proper technique to prevent injuries,” says Mark Herceg, Ph.D., director of neuropsychology at Burke Rehabilitation Hospital in White Plains, N.Y. “When students do sustain a concussion, the impact on their behavior and mood is just as important as whether the person comes back to play symptom-free.”

The most popular tool used to assess readiness to play is ImPACT—Immediate Post-Concussion Assessment and Cognitive Testing. This 20-minute, computerized test, which is in more than 7,400 schools, uses questions and games to measure attention span, memory, and reaction time. The tests should be given before and after injuries in consultation with neuropsychologists, Herceg says.

“Even though an athlete may be physically fine, if ImPACT scores have not returned to baseline levels, they will not be cleared to play,” Herceg says. “That happens quite often and shows the subtleties of concussions or mild traumatic brain injury. A lot of physical and sensory forms come back, but the cognitive—thinking, processing—take more time.”

Herceg suggests also using the “Sport Concussion Assessment Tool-3rd Edition,” a pen-and-paper test. This tool helps trainers perform a systematic and comprehensive sideline evaluation of each athlete with a suspected concussion. The player answers questions such as “What month is it?” or “Are you dizzy?” while a certified athletic trainer checks the player’s range of motion and balance.

At Newcastle High School in Oklahoma City, sensors installed recently in player’s helmets send concussion data to an iPad on the sidelines, according to WVNSTV.com.

Helmets and similar equipment do not prevent concussions but can reduce severity, Herceg says. The federal Youth Sports Concussion Act—which would ensure equipment manufacturers don’t falsely claim to prevent concussions—was introduced in the U.S. Congress earlier this year, and is now in committee.

Exertional sickling

Often confused with heat illness, exertional sickling happens to people with the sickle cell trait, which causes blood cells to change shape, or sickle, during intense activity and restrict blood flow.

“Since 2000, exertional sickling is the leading cause of non-traumatic deaths in division one (college) football,” says Scott Anderson, head athletic trainer at University of Oklahoma. “There have been four cardiac deaths, one exertional heat stroke death, one asthma death, and 10 exertional sickling deaths.

“Intensity is the issue,” Anderson says. “So you mitigate the intensity and control the sustained activity, and sports become relatively safe.”

While every state tests for the trait at birth, the information is rarely shared with parents and therefore, coaches. So Anderson and colleagues have been working to educate pediatricians, parents and athletes.

Symptoms include fatigue, lower extremity weakness, pain, cramping, shortness of breath and chest pain.

“Coaches need to instill in their program an appreciation and accommodations for an athlete with sickle cell trait, so if the athlete complains “I can’t catch my breath,’ the coach doesn’t say, ‘Suck it up and finish the workout,’ “ Anderson says. “Instead, the coach needs to say, ‘Go rest and recover,’ and then monitor the athlete with the understanding it can develop into a medical emergency.”

Model programs

Stephenville (Texas) ISD and Ewing (N.J.) Public School District have model student safety programs, says Casa. In Stephenville, AEDs are in every building and at every sporting event, including practices. All coaches are certified in CPR and first aid.

Ice baths are located outside with teams during practice and games. Sideline tents have cool mist fans, ice towels, and water. And the football team follows the state’s newly enacted heat acclimatization procedures, including starting with shorter workouts and phasing in the use of helmets and pads.

“We figure out a way to (finance all costs associated with safe sports), including having athletic trainers,” says Mike Carroll, assistant athletic director and head athletic trainer. “It’s hard to quantify the value of an athletic trainer, but when we are preventing or dealing with injuries and keeping athletes safe, that’s one less phone call the athletic director or principal has to take.”

Ewing athletic trainer David Csillan runs a similar student safety program, including following state heat acclimatization procedures and weighing athletes before and after practices. Carroll and Csillan say a key step in keeping students safe is sidelining athletes until they regain water weight lost during activity.

“If you don’t have enough fluids, your body is going to start shutting down,” says Csillan, who oversees 250 athletes. “You’ll be more fatigued, your brain won’t function as well, and you’re at a high risk for exertional heat stroke.”

Regina Whitmer is a freelance writer in New Jersey.

Reprinted with permission from District Administration. Sept. 2013