Battling Heat Stroke, Changing the Playing Field

Thu, 5 Nov. 2009 - 6:38 a.m. MT

Battling Heat Stroke, Changing the Playing Field


Douglas J. Casa, PhD, ATC, FACSM, FNATA

By Jeff Venables


            In August of 1985, sixteen-year-old Doug Casa was completing the last lap of a 10K race on a track in Buffalo, New York, when he collapsed. He stood up immediately, ran another 150 meters, and collapsed again. Casa, who says he had felt fine and that it had actually been one of his best race performances to date, spent the next seven hours in a coma induced by heat stroke.

            “That was the galvanizing moment,” says Casa, who is now the director of Athletic Training Education and a professor in the Department of Kinesiology at the University of Connecticut, where he teaches graduate-level courses with titles like “Preventing Sudden Death in Sports” and “Exertional Heat Stroke.” “For the last 24 years, my only interest has really been heat and hydration issues with athletes.”

            A certified athletic trainer and fellow of the American College of Sports Medicine, Casa is well known for his recent work within the National Athletic Trainers’ Association (NATA), which authored practice guidelines for high school football to keep players safe from heat stroke. He serves as the chair of NATA’s Pronouncement Committee. Additionally, as the chair of the expert panel of the Inter-Association Task Force on Exertional Heat Illnesses, Casa oversaw the creation of that committee’s Consensus Statement.

            At the Human Performance Laboratory at UConn, Casa spends a good deal of time researching and testing the latest findings of exercise science. He is a frequent presence in the medical tents of the Marine Corps, Boston, and other marathons, where the goal of keeping athletes safe is ongoing, and where new data on dehydration, heat illness, and fluid regulation never ceases to present itself.

            Casa is also a rather active member of AMAA, currently serving on the board of directors and as co-chair of the planning committee for AMAA’s annual symposiums at the Marine Corps Marathon. In recent years, so much of AMAA’s focus has been on hydration issues and exertional heat illness in marathoning, and Casa frequently speaks, and sometimes brings his students to speak, in D.C. and occasionally Boston.


A Running Life

            Born in Queens and raised in Selden, New York, in Long Island’s Suffolk County, Casa went from coming in nearly last in a co-ed mile race in a junior high track team tryout to building a very successful high school and college running career. “I was absolutely horrible initially. It’s easy to forget, it’s a skill to be learned, to run that hard for a certain length of time. I was used to playing sports where you run hard for, like, ten seconds.”

            He went on to run track and cross-country all four years at Allegheny College in Meadville, Pennsylvania, where he majored in biology and earned All-Conference and All-Region honors in his senior year in cross-country, establishing the school record in the steeplechase. He next attended graduate school at the University of Florida, where he received his master’s in Athletic Training and met his wife, Tutita—who was also on the track team. They now have three children, ages 3, 4, and 5, and live in Storrs, Connecticut, where the UConn campus is located. Before going on to teach, Doug received his PhD in Exercise Physiology there. The rural surroundings have given Casa the opportunity to take up trail running, and he says he hasn’t run on pavement in 10 years; he ran, more or less recreationally, in the National Trail Running Championships in Bend, Oregon, on September 13.


Making Sports Safer

            It’s not uncommon for heat-stroke victims to be asymptomatic, as Doug was back in 1985, with the first symptom being the actual collapse. This can make it a challenge to keep athletes safe in the heat, but Casa is passionate when he says that, with a few simple precautions, death from heat stroke is always preventable on the field of play. “You’re not always going to get a great early-warning sign, and that’s why you have to be sure at the high school and college level you always have an athletic trainer onsite to recognize it and immediately treat it. The message we’re trying to get out there is that heat stroke is a hundred percent survivable if you’re immediately cooled down,” Casa says. “We still have kids all across the country dying of heat stroke, but you can’t die if you’re immediately and aggressively cooled. You’re talking about a hundred-dollar Rubbermaid tub, ice, and water. Nobody at any level of sport can tell me they can’t afford that.”

            The proper medical staff onsite is essential, because coaches are not particularly good at, and shouldn’t necessarily be expected to be good at, diagnosing heat stroke. For example, a head injury can look like collapse from heat stroke. And a dangerous acute condition called exertional sickling, which can occur in people with the sickle-cell trait when they are performing very intense exercise, was actually the leading cause of death in college football players from 2000 to 2009. This condition is not commonly known among coaching staff. Casa points out that time is a key diagnostic factor. “A collapse ten minutes into a really intense workout, that’s not heat stroke. That’s not enough time to drag someone’s temperature up to 108 degrees.”

            Coaches, then, may be generally amenable to athletic trainers attending practices and games, but they are not always keen to accept NATA’s mandates when they actually alter well-honed practice schedules and methods. And to be sure, there is an important distinction to be made between knowing what’s happened to an athlete who goes down, and knowing what you should be doing to prevent it before it occurs.

            Football can be a perfect storm for heat stroke. In football, players are large, they perform frequent two- and sometimes three-a-day workouts in a lot of heavy padding, and the hardest time of their conditioning is also the hottest time of year in America: August. Add to this the militaristic attitude—the desire, as Casa says, “to make men out of boys”—and you’ve got a high-risk situation for the first several weeks of any new season.

            Most problems with heat happen in the first two to three days, with a steep acclimatization curve occurring over the first week. This is also when it’s less than clear what a given athlete’s baseline of heat tolerance is. Therefore, the mandatory guidelines for NCAA teams established in 2003 include: no two-a-day practices for the first five days, no full-gear practices until day six, and no two-a-days on successive days. The result? Nationally, there has not been one heat-stroke death in football at the college level during practice or games from 2003 to 2008; heat stroke deaths have only occurred during out-of-season conditioning.

            Casa wants results like this at the high school level, as well, and in June of this year, NATA released those guidelines. But the struggle for wide compliance is ongoing. “There are a lot of states that have absolutely no policy,” he says. He mentions one example where he discovered three three-hour practices in full gear on the first day. Politically, it is a long process, with little change overnight. But Casa is not afraid to ruffle a few feathers. “We did not create [the guidelines] for coaches,” he says. “We created them to help the athletes.”

            Things may be changing: In January, a high school football coach in Louisville, Kentucky, was charged by the state with reckless homicide for the heat-stroke death of a player there. Though there have always been civil cases, this is the first time in U.S. history that a criminal charge has been brought against a coach for his alleged involvement in a heat-stroke death. It seems fitting that Casa, who has been working his entire adult life to prevent coaches from claiming ignorance about safety in the heat, is the expert witness for the prosecution.


Coming Full Circle

            In 2001, Doug Casa found out who the athletic trainer was that saved his life in 1985. Doug was in Los Angeles giving a presentation in conjunction with an award he’d received when, at the conclusion of his talk, a woman in the audience went across the convention center to find one Kent Scriber, a professor of Exercise and Sport Sciences at Ithaca College in upstate New York.

            As Doug tells it, she asked Kent to recall the story he’s been telling in class for the last 15 years, whenever he covers heat stroke, about the sixteen-year-old runner in Buffalo who collapsed in 1985. She asked if Kent ever found out whose life he had saved that day, and he said no. She then related that she’d just heard the exact same story from the runner’s point of view in a talk that day: “Kent, you saved Doug Casa’s life.”

            Scriber and Casa knew of each other’s work—in fact, Scriber has often taught Casa’s research in the very same classes that he told the Buffalo story. Until that moment, he never knew it was his esteemed colleague whose life he’d saved. When Doug met Kent in Los Angeles that day, it was one man meeting the person who saved his life, and the other meeting someone who has devoted his entire professional career to understanding just what he’d done for him that day.

            To say that Doug Casa has gone into the correct field is an embarrassing understatement. For someone who only turned 40 last year, he’s forged a remarkable and important career in understanding, treating, and—through efforts matched in their ambition only by their success—preventing heat-related sudden death in athletes. Doug says, “It’s never hard for me to go to work on a given day.” From Kent Scriber’s perspective, if it wasn’t already, it must have been thrillingly obvious at that chance meeting in Los Angeles that Doug has found his calling. Since then, for the rest of us, it is certainly no less so.


Jeff Venables is the editor of Running & FitNews, the publication of the American Running Association, and a frequent contributor to the AMAA Journal.

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