Exertional Heat Stroke: Protective Measures to Take Before, During, and After a Crisis

Perhaps you remember Tevan, the freshman football player introduced in a previous article, “Why Body Temperature Is Essential in Heat Stroke.” While trying out for an offensive lineman position on the JV squad, he collapsed during water break and became unresponsive to his coaches’ questions.

When the athletic trainer, Sandra, was called over from another field, she considered the August heat, Tevan’s heat acclimatization status and size, and the two hours the team had been practicing. Sandra’s quick assessment led her to consider exertional heat stroke (EHS).

In the previous post, we discussed the best method for the athletic trainer to accurately obtain Tevan’s core body temperature—a rectal thermometer. Sandra confirms that Tevan’s body temperature is a dangerously high 106 degrees Fahrenheit. Now she can treat Tevan and begin the process of cooling his body.

Athletic trainers and other healthcare professionals who practice in the pre-hospital setting may hesitate to use a rectal thermometer to assess for exertional heat stroke, concerned that their actions could be misconstrued and set them up for a lawsuit by the athlete’s family. By taking action ahead of time and putting certain measures into place, this risk can be greatly reduced, protecting both the student athlete and the athletic trainer.

Protective Measures During an EHS Emergency

What measures should you take to protect yourself in a situation like this?

Measure #1—Ensure that your differential diagnosis is strong.

Sandra needs to narrow down the diagnosis to exertional heat stroke and one or two other conditions (perhaps a brain injury or a sickling crisis). This is done with a thorough history obtained from the coaches and the players as well as an assessment of the physical and environmental situation.

Measure #2—Share your reasoning and obtain permission.

Once Sandra has decided that a rectal temperature is required to confirm or refute EHS, she shares her reasoning verbally with her assisting AT colleague or a coach representative. Since she works at a secondary school and the number is close at hand, Sandra calls Tevan’s parent or guardian, explains her differential diagnosis, and obtains verbal agreement.

Measure #3—Secure an appropriate place to obtain the rectal temperature.

Ideally, this would be done in an AT facility, but since time is a factor, a designated sports medicine tent area with temporary privacy created using sheets and towels is also appropriate. Sandra also has help with her at all times.

When taking the temperature, Sandra efficiently inserts the rectal probe to the proper pre-marked depth and then pulls Tevan’s shorts or pants back up to proceed with treatment and monitoring of temperature and vitals.

Measure #4—Provide a witness.

Sandra enlists her AT colleague or pre-determined coach representative to assist and provide witness to appropriate medical care. Both the treatment location and the witness have been identified prior to the beginning of the sport season.

Pre-Season Preparations

In addition to these measures that will take place during the emergency, Sandra is also prepared with several measures she put in place before any emergency can occur:

1. She has the appropriate school administrator sign off on a rectal temperature acknowledgement form.
2. She has standing orders, including rectal temperature assessment, already in place with her team physician.
3. Her policies and procedures regarding EHS indicate that this assessment method will be used only when EHS is suspected. Every time she updates the policies and procedures document, she gets approval from key stakeholders.

Documenting the EHS Event

Following the event, Sandra writes detailed notes in her EMR or equivalent documentation system. These notes include all the situational factors in conjunction with the signs and symptoms that led her to suspect EHS and the reasons for ruling out other differential diagnoses. Additionally, the witnessing colleague or coach document also document what they observed separately.

It is unlikely that sexual assault/harassment will be a plausible argument in this case. Sexual assault is defined as sexual contact or behavior that occurs without the explicit consent of the recipient, including forced sexual intercourse, forcible sodomy, child molestation, incest, attempted rape, or fondling (stroke or caress lovingly or erotically). Sexual harassment is defined as unwelcome sexual advances, requests for sexual favors, and other verbal or physical harassment of a sexual nature.

It is difficult to think an appropriately obtained rectal temperature as described above could be misconstrued as any of these descriptors, but placing measures in place and taking appropriate action to protect yourself is always wise.