Episode Transcript
[00:00:03] Speaker A: Welcome to the @pit crew podcast. This high energy show dives deep into the world of sports emergency care. Join us as we explore cutting edge strategies, real world experiences and expert insights to help you step up your game in emergency care. We've got the tools, tips and stories you need to be ready when seconds matter. It's time for the @pit crew podcast. We have the green light in three, two, one.
[00:00:32] Speaker B: Welcome to the ATP crew podcast. I'm Ray Castle and today we're diving into a critical topic for athletic trainers and other sports medicine professionals. Preventing exertional heat illnesses in athletic settings. I'm excited to welcome a true expert in this field, Dr. Ron Walters. Dr. Walters is nationally recognized athletic trainer and consultant with over four decades of experience in sports medicine. With 27 years directing collegiate healthcare, Dr. Walters has presented over 3,000 times on athletic training topics. He's a respected author and has worked with high profile clients such as Cirque du Soleil, Major League Baseball, NFL and the Big 12 Conference. Additionally, he served as an expert witness on sports injuries and has led athletic medicine review boards for the University of Maryland and the University of Georgia. Inducted into the NATA hall of Fame in 2005, he's a sought after speaker, educator and expert in topics ranging from heat illness to concussion care. It's time to buckle up and let's get this show rolling. Good afternoon, Dr. Walter.
[00:01:40] Speaker C: Good to see you, Ray. Thank you so much for inviting me in today.
[00:01:44] Speaker B: Oh, it's a pleasure to have you here. It's always great to talk with you, as always. So, audience, this is what we have. We've got 11 laps here, 11 questions. Then we're going to get to, we'll get to a final, final lap in and then we'll do the victory lane and we'll be out of here. So on a hot topic of exertional heat illnesses. So let's get started. So, Dr. Walters, you've had an incredible career in sports medicine and athletic training. So looking back, what has inspired you to focus specifically on exertional heat illness prevention as a major aspect of your work?
[00:02:20] Speaker C: You know, Ray, I, you're right, I've been, I've been very, very blessed and pleased if Rod. You know that. So it's. I've just been very blessed in my career and you know, in 2018 when I was doing the consulting work, things were really starting to dry up and all of a sudden the George McNair case happened at Maryland. I was invited to come in and do an investigation there. We had another follow up at Garden City, Kansas and multiple other cases and all of a sudden got a lot of notoriety for identifying cases in and around exertional heat. I'm tired of seeing these preventable injuries abused and happen. And I just think there's not many things that we deal with that's 100% preventable. But this is low hanging fruit. And it's my passion right now to do everything I can to educate everything I can to push people to look at how we can prudently prevent these problems and identify them and treat them when they occur.
[00:03:23] Speaker B: Well, that's a great, you know, one is will lead into this next question which really hits into this as you talk, you know, for you had obviously have, you know, experience in different settings in the field and you've seen how exertional healing illness impacts athletes across various sports. I mean you've been on the front line, you know, obviously you've had to do case review for lawsuits, the, the, and in between prevention as well. But when you look back over that career, what can you break down like the evolution of management of dual heat illness and why is it we know that's a critical concern for athletic settings, but really about that, what's the evolution for what it was done like in the 70s and 80s and or so on and so forth. When you first started to today, you.
[00:04:06] Speaker C: Know, as a student in the 70s, we were taught about heat strokes and again we've heard that they were preventable.
I was something you probably didn't know that I was a benefactor to the education because in North Carolina there was a heat stroke in 1973 at the University of North Carolina, Chapel Hill, where a young man expired from exertional heat stroke. And it really got things rolling in North Carolina. So I was a student then and when I went to college, obviously this was a big focus and it's always been talked about as a preventable, a hundred percent preventable incident.
I think during my career I never saw a heat stroke. We saw one, a player one time where we intervened and he was obviously on his way to having a heat stroke, but we prevented that. So, you know, I think the assessment, you know, I was always around good doctors that were very, very aggressive. So we would even back in the 90s and early 2000s, we were checking core temperature to make sure people didn't have elevated values there. When I started doing the education programs, I had a talk about this and got a lot of pushback from a lot of people about assessing for core temperature. My, my basic deal is if we see a mental status change that tells us we have a heat stroke and we identify that by assessing that core temperature, as you well know. And so I just think that's paramount. And as I caught that, it was really pushed back. But when we made the report at the University of Maryland and we identified those as major problems, I think a lot of people started coming around and there's several documents now that have addressed that.
[00:05:47] Speaker B: So yeah, I've tried to relate that just as a sidebar, I've tried to relate it almost to, you know, if your child is sick at home and you take their, you're going to take their temperature and if they have a fever, you're going to give them medicine. And but like think about athletic setting side, I just want to refer to it, they're definitely looking sick. And if you're giving Tylenol, aspirin, whatever that is a child, cold water immersion is the, that's the, that's the medicine you have to have and the, and know what temperature is. So it's really no difference there. Absolutely, um, absolutely. So obviously we think about that you mentioned earlier about your, your past, your, your physicians you've worked with and other providers, EMs, et cetera, they're really skilled early on doing that. So when we think about preventing heat related illnesses or injuries, it requires that deliberate preparation and response. So what are, in your experience and you've seen this, what are the key preventative measures that medical personnel and coaches should implement to one, reducing the risk of heat illness, but how they plan that throughout the continuum and manage it if it does occur?
[00:06:59] Speaker C: Yeah, Ray, I think number one is, and with any incident that we're talking about here, we need to have an emergency action plan. We have to have a plan and then we have to have a procedure, a procedure specific to exertional heat stroke, exertional heat illness. So we want to prevent, by having acclimatization, by having conditioning and adhering to principles of transition. And I think this is something that we learned even more from COVID the importance of transition, that when we recover, we come back and we have to be progressive. We don't. We want to make sure we have conditioning, we want to make sure we have acclimatization, and we want to make sure that we're not using exercise as punishment. So if we do those things, I think that helps prevent. I think the other point about the conditioning of those things is looking at the weather, making sure people are not dehydrated. I mean, I could go on and on and on but those are the key elements. If we have a dehydrated person, we know they're predisposed to exertional heat illness. And so those are definite problems that we have to look at. And I'm not sure if that's the area you're talking about focusing on, but I really want to look at that because I think if you have athletes that come into practice and they're in shape, they're acclimatized to the setting and they're acclimated over a 14 day period, we know we're going to have less problems. But if we bring somebody in day one and let them go out and do a full practice and we're going to expose those people and we're going to have problems.
[00:08:32] Speaker B: Right. So it, which leads into this, all this, you know, the next, my next question is for you is, you know, we talk about there's a focus on hydration and cooling methods. I know you and I have talked about this a lot over, you know, for a considerable amount of time, but we don't, but it's not, not really a focus on specific body composition of the athlete such as, like you look at a soccer, we, we treat it as we're gonna treat a soccer player the same as an offensive lineman. And with that in mind, what are some of the common misconceptions and I think even looking at statistically, what are, you know, those misconceptions about preventing exertional heat illness that you've encountered in your work and right now, you see today, that may need to, we need to consider.
[00:09:20] Speaker C: Great question. You know, the big thing I see these, these illnesses, these deaths are happening to big Leshy players, offensive linemen. Studies show that over 97% of the problems are to people with a BMI of over 36. That's a large person. And so when we have that, that's why we call these exertional heat strokes, because they're exerting, they have large amounts of energy burning up in their body, they can't shed that heat to their surface. And that's why they have these problems. So number one is the body type. You know, the NCAA program of looking at temperature and environment has failed. You know, Todd Anderson did this great article where from 2000 to 2017 we had what, 32 different exertional problems, cases of football players dying in that same period. We've had zeros heat strokes in the NFL. So that's not apples to apples, but it's a time period and it shows you the numbers of Problems. The reason we're having problems in the college game is because we're not focusing on that. We can't condition these big linemen the same way we condition receivers or running back or defensive backs. So that's a major, major deal. The body habitat and how we condition these people and they cannot shed that body heat.
[00:10:51] Speaker B: Yeah, I think you see that even I, you know, I know like even I'll just throw off on like distant. We've talked like that. A lot of the data has been on, on distance runners and I do a lot of large, a considerable amount of working races. And I always joke it, I jokingly say that, you know, someone who's bigger like me, I'm, I'm less likely to see somebody like they're. If they're running a half marathon because they're running slower. They're not, they understand they, they're going to either tap. I'm not saying they tap out, but they may do that versus we see, you know, consistently in a heavier race like a, you know, the three and a half to four and a half hour runner. Those runners, those are the ones we see like when I go to Boston Marathon, it's a specific time. They're, they're full tilt. They're trying to push themselves. They push over that. So that's a great point. The changing. Well and I think it's a change the mindset, but also change the policy.
[00:11:45] Speaker C: Well and look at what Dr. Godek's research showed that you know, that some of the people were saying that we had a set amount of time and how much, how fast the heat comes down in these big players, it may take longer to cool them down. The point is if we assess that patient, we recognize those symptoms, we assess that patient, we treat them with cold water immersion until their Temperature comes to 102. It doesn't say a time factor. We don't know. And that's why it is so important. It's so critical that they use core temperature so we know where we are and how, how hot that person is.
[00:12:21] Speaker B: Yeah, it's, it's interesting that no one, it's not cookie cutter out. So you know, I've seen, not at all. I've seen a high level performing athlete in the tub, cold water immersion for like 35, 40 minutes and.
[00:12:35] Speaker C: Right.
[00:12:36] Speaker B: And because they kept jumping up and down, you don't cool them down below that 102 versus some maybe 20 minutes. But it gets into that. I think the point with that you bring out is just you've got to have the temperature consistent readings to have a clinical trajectory, you've got to know what right. What's going on. But also you think about exertional rhabdo or other issues are going on with the pain. There are certainly that metabolic collapse. So absolutely. So you mentioned earlier about protocol. We move forward. The next Eric question I want to ask you is you talk about, you mentioned about having protocols and the difference in procedures and EAP as well. So you've worked with a number of different organizations like the NFL, mlb, other in other groups as well.
So how do those protocols like if I'm an athlete trainer at a high school or at a small college or how do those protocols for presenting heat illness in professional sports differ from those at a collegiate or high school level?
[00:13:37] Speaker C: I think the guts of it are the same, Ray. I think the machines that we use to test those people, the machines we use to cool those people, the mechanisms we use may be different, but the science is the science.
When you get to 100, if you recognize that that person's in an exertional heat stroke, they've got to be cool. They have to be cool till they get to 102. So it doesn't make any difference. And when I do training, you know, I am very fortunate to work with NFL teams, major league baseball teams and go through these emergency scenarios for them. It's the same thing there that I do at the University of Kansas or I do it to any other institution or high school. So the science is the science.
[00:14:20] Speaker B: So, so getting into the like the science, you know, and we talk about there's a lot of medicine that doesn't have, does not have a set pathway and this is where we get into review boards. And I know you have a tremendous amount of experience on review board medical review boards for major universities. Like I mentioned University of Maryland and University of Georgia, you mentioned Kansas. And you know, especially I know you've gone on board after there have been some high profile incidents of exertional elon. So from the various levels, what lessons can schools and sports organizations learn from those unfortunate events and how they can improve their emergency action plans through the review needs to have a review board process. But all and I'm going to add another add on to that is how do you I'll come out in a second because I've got a follow up to that so go ahead and Okay.
[00:15:18] Speaker C: I think number one, I think number one the two questions I'm asked when I'm contracted to either review an incident or a death or something like, this is, number one, do we have appropriate procedures in place?
Policies are telling us we need to have a concussion plan. The procedure for how I deal with concussions at the University of South Carolina or an NC State or wherever I may be. That's how we handle that locale. So procedures are what I'm going to implement at my institution. So do we have appropriate procedures? And number two, are the. Were the procedures followed? That's the questions people want to know, and that's what we try to ascertain. So I think that's the. That's the critical thing. And I think procedures are so very important because now I know what I'm supposed to do. I know what I'm supposed to teach my staff to do. And we can review that, we can refer to that, and it's a document that we can use collectively to make sure we're on the same page. It's created, it's drafted, and then it reevaluated by our physician. It shared with legal counsel. We save that from year to year. And all the edits are tracked. So I can go back and look at what I did in 1994 and when did that change? And so I do think it's important to make a note here that I don't think it's fair from you to judge cases from 1998 on what we know today. We have to. And that's why it's important for you to know and your listeners to know they have a copy of their procedure from 98. They can look at that and they can say, this is what we did based upon what we knew then. And as it changed, we can see we can track those changes, and we can see that in our procedures. That was a long answer, but I hope you understand what I'm saying.
[00:17:17] Speaker B: It was spot on. I mean, just having those constantly. So as a side on that, like the review board process and we talk about the protocols and we know that medicine, you know, you want to implement something, but it's not out in the literature. And we know it may be a couple of years behind the process. I mean, just from a publication standpoint. So have you ever been case or situations where you've done these review boards where you're actually implementing policy that's not or considered adopting a protocol or a process within the protocol that does not have a lot of, like, I'm gonna say position statement evidence or best practices evidence, but there's a lot of literature that's leaning towards that to do that.
[00:18:03] Speaker C: Yeah, I think that you Know, people want to be on the cutting edge. You want to look at it at the same time, I think a great example, Ray, would be the 2023 concussion consensus statement. Yep. That came out in 23, published in 24. They met in 23, I think was published. Is that right? Met in 22, published in 23 and it actually got out in 24, whenever it was a year after it was published.
So I think that, you know, I think if we look at these things, you know, we may something maybe come out in 2023 and it may be a year and a half before it's implemented. I think there's a lot of people, really prudent people that are tenant to detail, they're going to get that in their best practices as soon as they can. And I think that's what's important. And so as we look at that, as we go across there, we want to update those changes. But I think that yes, there's a lot of times that we'll have information come out, there's a new information and we have to look at that and apply that. But again, it's by our consensus, it's by our advisors, it's by our group. I'm not making all those decisions, but we're going to share that with our group and we'll create a better procedure based upon that collective effort.
[00:19:26] Speaker B: Yeah. So you're standing with a team and that's. And the best eyes are looking on that and for that. Great. So we think about, you know, moving forward with heat illness and we know that it can happen quickly. It doesn't have this one, people think, oh, you gotta, you know, typically a long time ago used to be, oh, they gotta have hot dry skin. And this we know that that doesn't take take place.
It requires immediate action. So what are key steps that athletic trainers, the medical personnel they work with and coaches should take if they are the athlete is suffering from the exertional hydro student practice or gain.
[00:20:03] Speaker C: Great question. I think number one, we gotta have a plan to initiate this immediately. And so whenever we recognize a person that's having mental status change, they're clumsy, they're gooping up a drill, they're not being. They're just doing things that are not normal. That's maybe that's that mental status change, that's that central nervous system dysfunction. And so when I recognize those symptoms, I want to make sure I make an assessment. And that assessment is going to be that core temperature assessment. And if I see that core temperature north of 104, they're going to take that bath in that cold water. But I've educated my athletes about this, that this is what we're going to be. So I'm going to use that acronym of rapid recognition, rapid assessment, rapid treatment and then rapid advanced care. And we know that if we do that and if we identify that patient within 30 minutes we have 100 and cool that person within 30 minutes we have 100% success rate. Dr. Casa in all his research has 274 cases of exertional heat strokes that they have rapidly assessed, rapidly treated and what happened? They walk out of the tent and go home. You know, so that's a phenomenal statistic. So I think it's so important that we understand that we have to make that rapid assessment. If they get nothing else out of my webinar or this podcast today, I think that's critical. Bell, Bell's article is so good on that pre hospital care. One other point that is a consensus statement from emergency medicine. So when EMS says we're not, we're going to load and go, we're not going to stay and play and you know, cool first, transport second. We've got to do those things. And that's a pre hospital care by ems.
[00:22:01] Speaker B: Yeah. I would say the thing that looking at this, that I try to stress as well is you need to know what you're going to do at 102 temperature as well as 101.9 and below and then the same thing for 105 and 104.5 and that's those. And know what you're doing and not going to do that doesn't apply to everything.
Those are three different treatment processes right there.
[00:22:29] Speaker C: And realize when they get to 101.9 they're going to start falling quick.
[00:22:34] Speaker B: Yeah.
[00:22:35] Speaker C: And you may have rebounds.
[00:22:36] Speaker B: You see someone dropped from 108.9 around 1109 down to like 94. 93.
[00:22:43] Speaker C: Absolutely.
[00:22:44] Speaker B: I mean that's the, that's probably one of the worst things I've seen it just. And we couldn't. Yeah, we're trying to warm them up and you can't do that. You know, it's hard to do that. So.
[00:22:51] Speaker C: Absolutely.
[00:22:52] Speaker B: But the person eventually went home, so which is a good thing.
[00:22:55] Speaker C: Right.
[00:22:56] Speaker B: All right, so moving forward, you know, you've obviously consulted a lot of a wide range of organizations on EAP development, emergency response training as well as, you know, the policy procedure reviews. Can you give a quick example of where your like interventions you help prevent a serious heat related illness or illness. And I say could have died. They, they learned from that process to get better in what they did before versus what, what they did, you know, with that implementation and the takeaway from.
[00:23:28] Speaker C: That experience, you know, I don't have a specific case on exertional heat. I think there's a lot of them though, because we're preventing it. I mean, we're doing just that. If we didn't do the training we're doing, if we didn't do the education we're doing, they may have a lot more incidents. You know, I really feel good about the emergency scenario reviews that we do where we come into a school and we'll go through those different scenarios where it be sudden cardiac arrest, head and neck, major head truncal trauma, or exertional heat stroke. I know we had a client this year that we reviewed those protocols. Four days later they had a cardiac arrest just like one of those scenarios. And that client called and said, hey, we had a positive outcome here. Thanks, Roy. Your team, I said, you guys were buttoned up. That's not us, that's you. So what they do there is great. So I just love education. I love trying to help people. I love giving them the tools. And I don't, you know, I'm not, this is not about me. I just want to try to educate everybody I can because I think there is such a need for this as far as emergency action plan, as far as having great procedures for these, preventing exertional problems. And I think what you're doing here is tremendous to educate this stuff. And I think it's. That's why I always told you I would always be available to do this because I love it.
[00:24:54] Speaker B: I think you got, you got the invite to come back again already. We're not even done yet. So that's good. So thank you.
So obviously, you know, you've done not just from the experience, but You've done over 3,000 presentations on topics. I want to say the first off, I told my wife that and she's like, you need to get to work, so I got to catch up with you a little bit. So. But for anyone attending your workshops on heat related illnesses, what's the number one piece of advice you hope they walk.
[00:25:21] Speaker C: Away with for, for exertional heat problems?
[00:25:26] Speaker B: Yes, yes.
[00:25:27] Speaker C: I think, I think number one is just conditioning. You know, have making sure have conditioning, acclimatization and follow scientific prayer principles. If we'll look at the 2019 document on preventing catastrophic death from the NCAA, it's a great Document. It's got a great checklist. If you go down that checklist and look at all the things in there, I'll bet you're missing some of those and I bet that's what's causing problems. So if we'll do a good job, if we'll be aggressive and be prudent in our work, that's the deal. That's all I ask is people just to prevent these things. And Ben, you know, Ben Franklin said, analysis, prevention is worth a pound of cure. And I really believe that.
[00:26:07] Speaker B: Yep, it was a, that's about as simple as it gets. And make a difference.
[00:26:13] Speaker C: Absolutely.
[00:26:14] Speaker B: You know, we wrapped around a lot of different topics already in a very short time period today and 1, 2 questions and we're going, we're going to get bound to the final lap of this, of this podcast. But social media, obviously everything gets, you know, thrown out there. Anytime you see a number, you know, especially we, but we're continuing to see a large number, a number, certain number of athletes being hospitalized or dying from exertional heat illnesses. So what is, in your opinion, what's still the major hurdle or problem we're facing related to the exertional heat illnesses and how we can, what we can do to really eliminate that?
[00:26:59] Speaker C: I think the repeat the one I just said, I mean, I think we have that checklist. We look at that. How do we keep science in there?
How do we look at conditioning, how do we look at acclimatization?
Do we admire, do we acknowledge transition concepts so that we implement activity, we introduce new activities gradually? You know, we don't have rogue people out there conducting these programs. And I think anytime we do that, it will help us, it helps us prevent these problems.
[00:27:29] Speaker B: So one of the, excuse me, we got last lap before the final lap. So we know that exertional heat illness is not just a summer problem, it's a year round problem. Depending on the partner or country, part of the country you're in, or even the environment type event you're doing. What advice would give athletic trainers and others working in colder climates where the risk may be underestimated. They assume that, oh, it's only 65 degrees out today or 70 degrees out. That might, that mindset. What would you tell them?
[00:28:02] Speaker C: You gotta always have it on your radar. That's always on that differential. I think that it's always a potential there. We've seen them in February, we've seen them in, you know, October, We've seen them all around the year. We definitely seen it the summer. So it can happen at any time. I think you have to keep that on your radar. You have to be aware of it.
Your cold tubs always got to be accessible. I mean, whether you have cold tanks, whatever you have. But you got to have a plan. You got to. Failing to plan is planning to fail, and that's going to be a problem. So we have to have a plan.
[00:28:37] Speaker B: Great. So we've gone into the pit to pit stop. We've refueled for the last lap. We're coming out of the car, the light, the flag, and it's full tilt, full throttle. So five questions, five rapid questions, and here we go. Favorite move. Your favorite movie, probably brief. That's a good one. Can't go wrong with that. Favorite musician, George Straight.
[00:29:03] Speaker C: No doubt.
[00:29:03] Speaker B: You can't go wrong with that. The box set is phenomenal. And then, of course, he saw him in Baton Rouge. Here. He came here a couple years ago for Pretty phenomenal in Tiger Stadium. Favorite food?
[00:29:16] Speaker C: I don't know if I have a favorite. I love Italian. I love Mexican. I love Cajun. I love coming down your neighborhood. So, yeah, I love food, as you can see.
[00:29:23] Speaker B: Oh, yeah. I'm. I'm. I'm well versed in this as well, so. All right, so if you weren't doing your current career, what would you do?
[00:29:34] Speaker C: Well, Ray, that's a great question. I don't know. I love, love, love what I do. I am the luckiest guy in this business. Athletic training has been so good to me.
You know, I looked at physical therapy as an. As an undergraduate, and just. I didn't think. I love the team aspect of this. My. My hobby. The thing that I love to do outside of this is woodworking. So I don't think I could do that full time, though. But I. I promise you, I'm the most blessed guy in our profession.
[00:30:03] Speaker B: Fantastic. I love hearing that you don't work at all. You just go to play every day, and that's what I love. So, one question. Other than woodworking, what's a fun fact about you that audience may not know?
[00:30:17] Speaker C: My wife says I'm the best sous chef in the world. You know, we work hard all day, we come home at night, we fix dinner together, and if. If we're having lasagna and somebody's got to soften the onions and saute that. That's my job. So I'm her helper in the kitchen. But I love my wife. I love cooking with her, so that's always fun.
[00:30:36] Speaker B: I love that. That's awesome. That's a great, that's a great way to cooking up something good all the time. So absolutely. You love. So we're now in the victory lane. So thank you so much, Dr. Walters, for sharing your expertise. Before we wrap up, can you give us one final thought on what our audience should prioritize in the prevention and management of adjustable E doses?
[00:30:59] Speaker C: Stay on your toes, you know, you know, just assess these cases. Make sure you have a plan, run your medical time out, have your information, know what you're going to do.
Don't let these things catch you by surprise. Be prepared. I think that's always critical.
[00:31:16] Speaker B: So that's it for this episode of the ATP Group podcast. Big thanks to you, Dr. Walters, and for joining us and sharing your invaluable insights. But before we end, can you share with us how audience can contact you?
[00:31:32] Speaker C: Yeah, I have a website, rodwalters.com very easy and my contact information is on there. So if you send me an email, I can certainly do that. I'm on LinkedIn at Walters Inc. And on X is Walters Inc. But so I have several places there. But I, you know, I do Facebook for social stuff, but not a lot of work stuff. So that's, that's the primary way.
[00:31:54] Speaker B: Great. Well, thank you so much again and audience, thank you so much for participating today. And be sure to like, subscribe and share this episode with your community. And if you love what you heard, don't forget to leave us a review. Until next time, we are out of here.
[00:32:14] Speaker A: Thank you for joining us on the eight.
We encourage you to, like, subscribe and join our community.
For more information about this podcast show, visit www.actionmed.co. podcast this show is a production of ActionMedical Consultants, LLC.
The medical information provided within this program reflects the opinions of the hosts and guests and is intended for informational and educational purposes only. It should not be considered as a substitute for professional medical advice, diagnosis or treatment. Always seek the guidance of your healthcare provider with any questions you may have regarding a medical condition or treatment.
