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American football and fatal exertional heat stroke: a case study of Korey Stringer

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Abstract

On August 1, 2001, Korey Stringer, a Pro Bowl offensive tackle for the Minnesota Vikings, became the first and to date the only professional American football player to die from exertional heat stroke (EHS). The death helped raise awareness of the dangers of exertional heat illnesses in athletes and prompted the development of heat safety policies at the professional, collegiate, and interscholastic levels. Despite the public awareness of this death, no published study has examined in detail the circumstances surrounding Stringer’s fatal EHS. Using the well-documented details of the case, our study shows that Stringer’s fatal EHS was the result of a combination of physiological limitations, organizational and treatment failings, and extreme environmental conditions. The COMfort FormulA (COMFA) energy budget model was used to assess the relative importance of several extrinsic factors on Stringer’s EHS, including weather conditions, clothing insulation, and activity levels. We found that Stringer’s high-intensity training in relation to the oppressive environmental conditions was the most prominent factor in producing dangerous, uncompensable heat stress conditions and that the full football uniform played a smaller role in influencing Stringer’s energy budget. The extreme energy budget levels that led to the fatal EHS would have been avoided according to our modeling through a combination of reduced intensity and lower clothing insulation. Finally, a long delay in providing medical treatment made the EHS fatal. These results highlight the importance of modern heat safety guidelines that provide controls on extrinsic factors, such as the adjustment of duration and intensity of training along with protective equipment modifications based on environmental conditions and the presence of an emergency action plan focused on rapid recognition and immediate on-site aggressive cooling of EHS cases.

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References

  • Ainsworth BE, Haskell WL, Herrmann SD, Meckes N, Bassett Jr DR, Tudor-Locke C, Greer JL, Vezina J, Whitt-Glover MC, Leon AS. The compendium of physical activities tracking guide. Healthy Lifestyles Research Center, College of Nursing & Health Innovation, Arizona State University. Retrieved 12 May 2015 from the World Wide Web. https://sites.google.com/site/compendiumofphysicalactivities/

  • Armstrong LE, Casa DJ, Millard-Stafford M, Moran DS, Pyne SW, Roberts WO (2007) American College of Sports Medicine position stand: exertional heat illness during training and competition. Med Sci Sports Exerc 39(3):556–557

    Article  Google Scholar 

  • Armstrong LE, Johnson EC, Casa DJ, Ganio MS, McDermott BP, Yamamoto LM, Lopez RM, Emmanuel H (2010) The American football uniform: uncompensable heat stress and hyperthermic exhaustion. J Athl Train 45(2):117–127

    Article  Google Scholar 

  • Associated Press (2001) Vikings tackle Stringer dies from heatstroke. 31 July 2001

  • Bentley M, Stallins JA (2008) Synoptic evolution of Midwestern U.S. extreme dew point events. Int J Climatol 28:1213–1225

    Article  Google Scholar 

  • Brotherhood JR (2008) Heat stress and strain in exercise and sport. J Sci Med Sport 11:6–19

    Article  Google Scholar 

  • Brothers RM, Mitchell JB, Smith ML (2004) Wearing a football helmet exacerbates thermal load during exercise in hyperthermic conditions. Med Sci Sports Exerc 36(5):S48

    Google Scholar 

  • Brown RD, Gillespie TJ (1995) Microclimate landscape design. Wiley

  • Brown RD, Gillespie TJ (1986) Estimating outdoor thermal comfort using a cylindrical radiation thermometer and an energy budget model. Int J Biometeorol 30:43–52

    Article  CAS  Google Scholar 

  • Brown RD, Vanos JK, Kenny NA, Lenzholzer S (2015) Designing urban parks that ameliorate the effects of climate change. Landcape Urban Plan 138:118–131

    Article  Google Scholar 

  • Campbell GS (1977) An introduction to environmental biophysics. Springer-Verlag, New York

    Book  Google Scholar 

  • Daren T, Coris EE, Casa DJ, DeMartini J, Bain A, Walz S, Jay O (2014) Maximum heat loss potential is lower in football linemen during an NCAA summer training camp because of lower self-generated air flow. Journal of Strength and Conditioning Research 28(6):1656–1663

    Article  Google Scholar 

  • De Freitas CR, Dawson NJ, Young AA, Mackey WJ (1985) Microclimate and heat stress of runners in mass participation events. J Clim Appl Meteorol 24:184–191

    Article  Google Scholar 

  • De Freitas CR, Ryken MG (1989) Climate and physiological heat strain during exercise. Int J Biometeorol 33:157–164

    Article  CAS  Google Scholar 

  • Demartini JK, Casa DJ, Stearns R, Belval L, Crago A, Davis R, Jardine J (2015) Effectiveness of cold water immersion in the treatment of exertional heat stroke at the Falmouth Road Race. Med Sci Sports Exerc 47(2):240–245

    Article  Google Scholar 

  • Epstein Y, Moran DS (2006) Thermal comfort and the heat stress indices. Ind Health 44:388–398

    Article  Google Scholar 

  • Fiala D, Lomas KJ, Stohrer M (2007) Dynamic simulation of human heat transfer and thermal comfort. In: Mekjavic S, Kounalakis S, Taylor NAS (eds) Proceedings of the 12th International Conference on Environment Ergonomics, Piran Slovenia, 17–19 August 2007, pp 513–515

  • Fox EL, Mathews DK, Kaufman WS, Bower RW (1966) Effects of football equipment on thermal balance and energy cost during exercise. The Research Quarterly 37(3):332–339

    CAS  Google Scholar 

  • Godek SF, Godek JJ, Bartolozzi AR (2004) Thermal responses in football and cross-country athletes during their respective practices in a hot environment. J Athl Train 39(3):235–240

    Google Scholar 

  • Gonzalez RR, Cheuvront SN, Montain SJ et al (2009) Expanded prediction equations of human sweat loss and water needs. J Appl Physiol 107:379–388

    Article  CAS  Google Scholar 

  • Grundstein A, Ramseyer C, Zhao F, Pesses J, Akers P, Qureshi A, Becker L, Knox J, Petro M (2012) A retrospective analysis of American football hyperthermia deaths in the United States. Int J Biometeorol 56(1):11–20

    Article  Google Scholar 

  • Grundstein A, Williams C, Phan M, Cooper E (2015) Regional heat safety thresholds for athletics in the contiguous United States. Appl Geogr 56:55–60

    Article  Google Scholar 

  • Havenith G (2001) Human surface to mass ratio and body core temperature in exercise heat stress—a concept revisited. J Therm Biol 26:387–393

    Article  Google Scholar 

  • Hitchcock KM, Millard-Stafford ML, Phillips JM, Snow TK (2007) Metabolic and thermoregulatory responses to simulated American football practice in the heat. Journal of Strength and Conditioning Research 21(3):710–717

    Google Scholar 

  • Johansson E, Thorsson S, Emmanuel R, Krüger E (2014) Instruments and methods in outdoor thermal comfort studies—the need for standardization. Urban Clim 10:346–366

    Article  Google Scholar 

  • Kenny NA, Warland JS, Brown RD, Gillespie TG (2009a) Part A: assessing the performance of the COMFA outdoor thermal comfort model on subjects performing physical activity. Int J Biometeorol 53:415–428

    Article  Google Scholar 

  • Kenny NA, Warland JS, Brown RD, Gillespie TJ (2009b) Part B: revisions to the COMFA outdoor thermal comfort model for application to subjects performing physical activity. Int J Biometeorol 53:429–441

    Article  Google Scholar 

  • Kerr ZY, Casa DJ, Marshall SW, Comstock RD (2013) Epidemiology of exertional heat illnesses among U.S. high school athletes. Am J Prev Med 44(1):8–14

    Article  Google Scholar 

  • Kerslake D (1972) The stress of hot environments. Cambridge University Press, London

    Google Scholar 

  • Kucera KL, Klossner D, Colgate B, Cantu RC (2016) Annual survey of football injury research. National Center for Catastrophic Sport Injury Research, report 2016-01

  • Kulka TJ, Kenney WL (2002) Heat balance limits in football uniforms. The Physician and Sports Medicine 30(7):29–39

    Article  Google Scholar 

  • Liljegren JC, Carhart RA, Lawday P, Tschopp S, Sharp R (2008) Modeling the wet bulb globe temperature using standard meteorological measurements. J Occup Environ Hyg 5:645–655

    Article  Google Scholar 

  • Mathews DK, Fox EL, Tanzi D (1969) Physiological responses during exercise and recovery in a football uniform. J Appl Physiol 26(5):611–615

    CAS  Google Scholar 

  • McCullough EA, Kenney WL (2003) Thermal insulation and evaporative resistance of football uniforms. Med Sci Sports Exerc 35(5):832–837

    Article  Google Scholar 

  • Minard D (1961) Prevention of heat casualties in Marine Corps recruits. Mil Med 126:261–272

    CAS  Google Scholar 

  • Montain SJ, Latzka WA, Sawka MN (1995) Control of thermoregulatory sweating is altered by hydration level and exercise intensity. J Appl Physiol 79(5):1434Y9

    Google Scholar 

  • Montieth J, Unsworth M (2008) Principles of environmental biophysics, 3rd edn. Elsevier

  • Mora-Rodriguez R (2012) Influence of aerobic fitness on thermoregulation during exercise in the heat. Exercise & Sport Sciences Reviews 40(2):79–87

    Article  Google Scholar 

  • Mueller FO, Colgate B (2010) Annual survey of football injury research 1931–2009. Prepared for: The American Football Coaches Association, The National Collegiate Athletic Association and the National Federation of State High School Associations. 30 pp

  • National Renewable Energy Laboratory (NREL). National Solar Radiation Database 1991–2005 update: user’s manual. Technical Report NREL/TP-581-41364 April 2007; 472 pp

  • Patel T, Mullen SP, Santee WR (2013) Comparison of methods for estimating wet-bulb globe temperature index from standard meteorological measurements. Mil Med 176:926e933

    Google Scholar 

  • Petro M (2011) Late-summer heat waves and their impact on hyperthermia-related deaths in football players. Thesis, University of Georgia

  • Pryor RD, Casa DJ, Holschen JC, O’Connor FG, Vandermark LW (2013) Exertional heat stroke: strategies for prevention and treatment from the sports field to the emergency department. Clinical Pediatric Emergency Medicine 14(4):267–278

    Article  Google Scholar 

  • Rav-Acha M, Hadad E, Epstein Y, Heled Y, Moran DS (2004) Fatal exertional heat stroke: a case series. Am J Med Sci 328(2):84–87

    Article  Google Scholar 

  • Richards M, Havenith G (2007) Progress towards the final UTCI model. In: Mekjavic SN, Kounalakis SN (eds) Proceedings of the 12th International Conference on Environment Ergonomics. N.A.S. Taylor, pp 521–524

  • Sawka MN, Burke LM, Eichner ER et al (2007) American College of Sports Medicine position stand. Exercise and fluid replacement. Med Sci Sports Exerc 39:377–390

    Article  Google Scholar 

  • Shibasaki M, Wilson TE, Crandall CG (2006) Neural control and mechanisms of eccrine sweating during heat stress and exercise. J Appl Physiol 100:1692–1701

    Article  Google Scholar 

  • Vanos JK, Warland JS, Gillespie TJ et al (2012b) Human energy budget modeling in urban parks in Toronto, ON and applications to emergency heat stress preparedness. J Appl Meteorol Clim 51:1639–1653

    Article  Google Scholar 

  • Vanos J, Warland J, Gillespie T, Kenny N (2012a) Thermal comfort modelling of body temperature and psychological variations of a human exercising in an outdoor environment. Int J Biometeorol 56:21–32

    Article  Google Scholar 

  • Vanos J, Warland J, Gillespie T, Kenny N (2012c) Improved predictive ability of climate-human-behaviour interactions with modifications to the COMFA outdoor energy budget model. Int J Biometeorol 56:1065–1074

    Article  CAS  Google Scholar 

  • Vanos JK, Warland JS, Kenny NA, Gillespie TJ (2010) Review of the physiology of human thermal comfort while exercising in urban landscapes and implications for bioclimatic design. Int J Biometeorol 54:319–334

    Article  Google Scholar 

  • Yao R, Li B, Liu J (2009) A theoretical adaptive model of thermal comfort—adaptive predicted mean vote (aPMV). Build Env 44:2089–2096

    Article  Google Scholar 

Download references

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Authors and Affiliations

  1. Department of Geography, University of Georgia, Athens, GA, 30602, USA

    Andrew Grundstein & John A. Knox

  2. Scripps Institution of Oceanography, University of California at San Diego, La Jolla, CA, 92093, USA

    Jennifer Vanos

  3. School of Medicine, University of California at San Diego, La Jolla, CA, 92093, USA

    Jennifer Vanos

  4. Department of Kinesiology, University of Georgia, Athens, GA, 30602, USA

    Earl R. Cooper

  5. Department of Kinesiology, Korey Stringer Institute, University of Connecticut, Storrs, CT, 06269, USA

    Douglas J. Casa

Authors
  1. Andrew Grundstein
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  2. John A. Knox
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  3. Jennifer Vanos
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  4. Earl R. Cooper
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  5. Douglas J. Casa
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Correspondence to Andrew Grundstein.

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Grundstein, A., Knox, J.A., Vanos, J. et al. American football and fatal exertional heat stroke: a case study of Korey Stringer. Int J Biometeorol 61, 1471–1480 (2017). https://doi.org/10.1007/s00484-017-1324-2

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  • DOI: https://doi.org/10.1007/s00484-017-1324-2

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