If heatstroke deaths can be prevented as experts say ...

03:45 PM CDT on Tuesday, October 5, 2004

By GARY JACOBSON, TIM MacMAHON and JASON TRAHAN / The Dallas Morning News

Top sports medicine experts say no football player should ever die from heatstroke.

This is the story of one who did.

As most team members headed to the weight room after the first practice of the season on the first Monday of August, a friend helped Eric Brown into the training room – to get out of the sun, drink some water and cool off. It was hot and humid, but the Carter High School starting center and team co-captain said he was OK.

Teammate Zach Thurman, sick from the heat, remembers looking over at Eric, who was face down on the next training table and not talking.

Zach, a senior backup quarterback, had trouble breathing and was not responding fully, so Carter athletic trainer Charles Kaiser moved him to a nearby hallway where there was more ventilation. When Zach didn't improve, Mr. Kaiser called an ambulance.

Michael Hogue / DMN

Paramedics spent 20 minutes with Zach before taking him to the hospital. No one told them about Eric, said Dallas Fire-Rescue Capt. Jesse Garcia. Eric was still in the training room.

An hour later, the same ambulance and crew went to Eric's house after a 911 call. Four firefighters also responded. The 5-10 senior, who weighed about 300 pounds, had collapsed soon after friends took him home.

Damaged by too much heat for too long a period – heatstroke – Eric's internal organs were failing. He never recovered.

All heatstroke victims will recover if immediately put in an ice water bath, says Douglas Casa, director of athletic training education at the University of Connecticut and chairman of a panel of experts on heat illness caused by exercise. Often, training procedures don't reflect current knowledge, his group said.

"You can never prevent all cases of heatstroke, but you can prevent death from heatstroke," Dr. Casa said, citing hundreds of case studies.

The National Center for Catastrophic Sport Injury Research, the authority on football injuries at all levels from the sandlots to the pros, calls football heatstroke deaths "unacceptable."

"All the literature indicates that heatstroke deaths are preventable," said Frederick Mueller, the center's director and chairman of the department of exercise and sport science at the University of North Carolina.

Using documents from the Dallas Independent School District obtained through the Texas Public Information Act, and through interviews conducted immediately after and since the incident, The Dallas Morning News reconstructed the nearly 3½-hour Carter practice Aug. 2, and the period afterward.

Mr. Kaiser, the trainer, and Carter coach Allen Wilson say DISD is not allowing them to talk about the incident, other than Mr. Wilson's comments in the first days after Eric's death.

In response to faxed questions from The News, the district's chief spokesman, Donald Claxton, issued a statement that said the district "is not at liberty to discuss the personal nature of many of the questions."

"We are not declining to comment," the statement said. "We feel that such matters are better left to qualified professionals who are directly associated with this matter."

From 1995 through 2001, 21 football players around the country died from heatstroke, according to Dr. Mueller's center. The Carter incident came after two seasons without heatstroke deaths. It attracted widespread media attention, prompting athletic trainers and medical experts to reissue heat guidelines.

Some, including Dr. Casa, have questioned whether Mr. Wilson's first practice was too strenuous. It ended just before noon, when the heat index, a measure of how hot the combination of temperature and humidity feels, was 105. Gradual heat acclimation over a week or two is the best approach, experts say. Mr. Wilson says his first practice every year is usually his longest.

"Almost every heatstroke death in football over the past 20 years has been on the first or second day of practice," said Larry Kenney, past president of the American College of Sports Medicine and a professor at Penn State University. "That points to a lack of heat acclimation."

For more than an hour after practice, the documents and interviews show, Mr. Kaiser monitored three players with possible heat illness. A fourth player, who never came to the training room, would go to the hospital from home late in the afternoon. The player spent three days in the hospital, but his family requested that no information on his condition be released.

In addition to moving Zach into the hallway, Mr. Kaiser contacted the mother of junior tight end Kelvin Smith, who had cramps. The trainer wouldn't let Kelvin, 6-3, 220 pounds, go home until his mother came and got him. Kelvin and Eric "were responsive and appeared to be in good shape," Mr. Kaiser said in a handwritten statement about the incident obtained from the DISD.

The ambulance for Zach arrived at 12:41 p.m., about five minutes after Mr. Kaiser called. The paramedics found Zach and Mr. Kaiser waiting in the hallway.

Zach still couldn't catch his breath. The rescue crew determined that he was dehydrated but not in a life-threatening condition, said Capt. Garcia, speaking for the two crew members, who declined to be interviewed directly.

In that circumstance, because Zach is a minor, the paramedics needed parental permission before they could begin treatment or transport him. They moved Zach to the ambulance and called his father, who said he wanted to see his son before granting permission.

Shortly after they spoke to Zach's father, Capt. Garcia said, Zach began cramping, a development the paramedics considered serious enough to begin treatment. They administered intravenous fluids and oxygen and gave him a physical exam. Zach's father, James Thurman, arrived, and the ambulance took Zach to the hospital at 1:01 p.m.

While the crew was at the school, Capt. Garcia said, no one told the paramedics that anyone else was sick or needed attention.

When Mr. Kaiser returned to the training room, Eric sat in a chair drinking Gatorade and water. He told Mr. Kaiser he felt better and asked to leave with friends. Mr. Kaiser agreed because Eric said there would be someone at home to watch him.

Kelvin remained in the training room until his mother arrived.

DISD documents do not record any actions to take the core body temperature of players or to put players into ice water baths. Zach said no one took his temperature at the school. Experts consider core temperature the best way to diagnose heatstroke and ice water baths the best way to treat it.

Among the questions faxed to the school district were specific inquiries about ice baths and whether core body temperature readings had been taken. The district did not answer those questions.

Exercise-induced heatstroke can be especially hard to diagnose. Sometimes the symptoms are obvious, as when an athlete collapses. Sometimes the symptoms are subtle. A player may say he's OK but may show slight changes in behavior that only someone who knows him well would detect. Noticing any change in central nervous system function, however small, is crucial to diagnosing heatstroke, experts say.

If heatstroke is not diagnosed and treated quickly, the result can be what Dr. William Roberts, president of the American College of Sports Medicine and an associate professor at the University of Minnesota Medical School, calls "a slow lapse into oblivion." The body's internal systems break down as cell destruction increases. Heart and liver function degrades. The kidneys stop filtering. The brain stops functioning.

That's what happened to another 300-pound lineman, the Minnesota Vikings' Korey Stringer, during the second day of preseason training camp in 2001, Dr. Roberts says. And he suspects that's what happened to Eric Brown.

Many in sports medicine will never see heatstroke caused by exercise, Dr. Roberts said. "The first one can sneak up on you," he said.

The weather didn't sneak up on anyone Aug. 2. The forecast in the paper that morning called for a high temperature of 98 degrees and a heat index of 103. There also was a level-red, or unhealthy, pollution watch. Practice guidelines followed by the district advise extreme caution on such days.

Most DISD practices are conducted without a trainer present. Carter is one of only two DISD schools (the other is Skyline) with on-site trainers, according to the district's head trainer, Phil Francis. The 19 other high schools share 10 trainers who work out of centralized locations.

Mr. Kaiser, 28, a certified athletic trainer, began work at Carter in 2002 after graduating from Stephen F. Austin State University in Nacogdoches, majoring in kinesiology. Mr. Francis said Mr. Wilson, in his third year at Carter, requested an on-campus trainer.

As the Carter players arrived for an 8 a.m. team meeting in their weight room, the temperature was already 80 degrees and the heat index 86 at nearby Dallas Executive Airport. Practice began at 8:30 with calisthenics and 20 minutes of conditioning, according to a written practice schedule obtained by The News. The players wore no pads, only shorts, T-shirts and helmets, as required during initial workouts.

Zach Thurman, 6-2, 197 pounds, said in an interview that he felt sick about midway through position drills during the second hour of practice. "I was just feeling more tired than usual and couldn't get my breath back," he said. He didn't say anything to coaches or trainers.

At 10:53, as the practice approached the 2 ½-hour point, the temperature at Executive Airport was 90 and the heat index 103.

Courtesy Brown family

Carter center Eric Brown told school officials he was OK but collapsed at home after practice.

During conditioning sprints, which began at 11:30 a.m., Zach said he had to lie down several times. Coaches and others poured water on him.

Mr. Wilson, one of the most successful and respected coaches in the state, always finishes his practices with sprints of about 40 yards. He starts with 16 sprints and reduces the number by one after every game in a symbolic countdown to the state championship. If a team plays 16 games in a season, that last one will be for the state title. In 22 years as a head coach, his teams have won two titles, at Paris and Tyler John Tyler.

Those who worked with Mr. Wilson at his previous coaching jobs say he had no serious heat-related problems before.

Eric didn't appear in obvious trouble during practice. The usual signs, such as vomiting, didn't appear, Mr. Wilson said after the incident.

This was Eric's third year in Mr. Wilson's system, so he knew what to expect in the first practice of the season. His autopsy report, though, said he weighed 312 pounds, 37 pounds more than his listed weight in game programs from the previous season. Dr. Roberts estimates that the intravenous fluids administered by rescue workers and emergency room personnel could have accounted for up to 8 pounds of the extra weight.

Practice ended at about 11:50 a.m., according to Mr. Kaiser's statement. The temperature at Executive was 92 and the heat index 105.

Dr. Kenney, an expert on human temperature regulation, helped develop widely used practice guidelines for a range of temperature and humidity readings.

Reviewing the readings during each hour of Carter's first practice at the request of The News, Dr. Kenney said the conditions were probably "right at the upper limit for heat balance," or the ability of a person's core body temperature to level off during a workout before becoming dangerous.

There are variables, such as the exertion level of the practice and the amount of protective gear worn, but the guidelines for conditions encountered during Carter's practice are for 15 to 20 minutes of activity followed by five to 10 minutes of rest and fluid breaks.

Mr. Wilson's practice schedule lists two water breaks, 10 minutes each at 9:05 and 10:20. But players and Mr. Wilson said that there were six water breaks and that water was available throughout the practice.

Jim Mahoney / DMN

Carter head football coach Allen Wilson instructed players during an Aug. 6 workout on the school's practice field. He's been told by DISD not to speak about a player's death from heatstroke during a 3½-hour practice.

After practice, Desmond Jones, a friend of Eric's and a former Carter player, says he saw Eric and Mr. Kaiser walking off the field together. Mr. Jones, who now plays at Southern Methodist University, caught up with them, and Eric leaned on him, Mr. Jones said. He helped Eric into the training room.

Another friend and teammate, Jerry Prater Jr., checked on Eric before going to lift weights. He said Eric was trembling, his eyes closing, and was barely able to hold the water he was trying to drink.

Eric, though, consistently said he was fine when asked by Mr. Kaiser, coaches and friends.

Because of their mass, big people are especially at risk for heatstroke, experts say. They heat up fast and cool down slowly.

Another possible risk factor would be a viral illness in the week before heat exposure. Debra Brown said her son had no such illness. "He had never been sick at all," Mrs. Brown said in an interview.

Eric's autopsy report said he had a body temperature of 105.6 degrees, taken at least two hours after practice ended, according to the reconstructed timeline of events. Dr. Kenney estimates that Eric's core temperature right after practice was 108 to 110 degrees.

"That's a deadly temperature," Dr. Roberts says.

The only way to accurately measure core body temperature is rectally.

A core temperature greater than 104 is cause for concern. Some experts think a person could survive a temperature higher than 110, if the duration were short.

With heatstroke, immediate cooling is recommended before the victim is transported to the hospital because the key to survival is how high the temperature goes and how long it stays there. Some experts call it the time "under the heat curve."

Dr. Roberts says it's not an exact science, but as a general rule he multiplies the number of degrees over 105 by the number of minutes at that temperature. If the result is 60 or less, patients usually can be treated and do fine.

In Mr. Stringer's case, his core temperature was 108.8 when he got to the hospital, about an hour after he left the Minnesota Vikings practice field. Dr. Roberts estimates that Mr. Stringer totaled 360 degree-minutes under the heat curve. Vikings trainers gave him iced towels but did not submerge him in an ice water bath or take his core body temperature.

Louis DeLuca / DMN

Carter players wore No. 50 on their helmets, marking the jersey number of Eric Brown, at a game Aug. 27. The student died after the team's first practice, where the heat-index was 105 degrees.

If Eric's core temperature were greater than 108 at the end of practice, he would have reached Dr. Roberts' threshold of 60 within 20 minutes. The paramedics didn't get to the hallway to treat Zach until about 50 minutes after practice, meaning that even if they had been told about Eric, his outcome was uncertain. Capt. Garcia said the rescue squads carry ice packs, but they are not set up to put people in ice water baths.

At some running races and in some military training, Dr. Roberts says, medical and training personnel routinely prepare ice water baths in advance, in case they need them. After the Stringer case, more pro and college football teams are doing the same, Dr. Kenney says.

Some area high schools also prepare ice water baths in advance for players who may need them.

"During double sessions, we practice at 8 a.m., and I make it [the bath] at 7:30," said Jason Barnes, an athletic trainer at Frisco High School.

Dr. Kenney said an ice water bath cools a person at 20 times the rate of air conditioning. A $12 plastic wading pool will work. "If in doubt, dump the kid in ice water," Dr. Kenney said. "I don't think there's any real downside."

Sometime after 1 p.m., after Mr. Kaiser cleared him, Eric left the high school with Jerry Prater, Mr. Jones and Mr. Jones' brother, Dearrius, a junior varsity linebacker. Eric said he was hungry, said Mr. Jones, who drove. So they stopped at the McDonald's drive-through. Eric ate in the car on the way home.

When the friends dropped off Eric, Mr. Jones said, he looked tired, but nothing out of the ordinary after a tough practice. Jerry said Eric looked fine.

He wasn't.

At 2 p.m., Eric's younger sister called 911, sobbing. "My brother," she told the emergency dispatcher, according to a tape recording of the call, "... he's on the floor shaking and foam's coming out his mouth."

At 3:09 p.m., Eric died at Methodist Charlton Medical Center, where Zach Thurman was still receiving treatment.

Zach said Carter players and parents gathered at the hospital told him that an ambulance had been sent for Eric, and, a short time later, that Eric had died. Zach would be released at 11 p.m. Doctors told him he had heat exhaustion.

Other than his weight, Eric's autopsy report describes a pretty normal 17-year-old. His drug and alcohol screens were negative.

The cause of death, the report said, was accidental "hyperthermia."

For Eric Brown, with accompanying organ failure, that means heatstroke.

E-mail gjacobson@dallasnews.com

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