Its my honor to introduce our next speaker, colonel francis oconnor, m. D. , whos the professor and chair of military and emergency medicine. If you never been there actually worth a visit here francis took me around and its really a great place where we have training, medical training for those are going to be serving in our country and providing service to the men and women who serve in a country. Hes also a leading voice for exertional illness, sickle cell trait. Hes leading a major study and internist and really sicklecell trait even better and he certainly has been a mentor and a friend to john and me and others at the ncaa and trying to guide us to go in the right direction. So thank you for coming here today. Well, thank you. Its an absolute honor to be here to honor derek sheely. As a father of three sons im still shaken. Ms. Sheely, listening to your words and your passion, i will not forget. I will not forget. Im going to be moving away from cardiac and we will talk about some and other entities of exertion illness. As brian also stated i am with the department of defense and all the opinions i have today are those of myself and not to be construed with the department of defense uses or cases. August 2001, cory stringer, practicing full gear, outofstate here in the midwest, heat index 110. Stringer vomited three times, walked to an airconditioned shelter, start to complain of distance and became dizzy and began breathing heavily. Darrell boyd and a Football Player, 19, 2006 collapsed on the field in texas after exerting himself. He and his teammates as very common football ran 16 consecutive 100yard sprints, almost a full mile. Early on you showing distress picket difficulty breathing, complaining of leg tightness, trouble standing, subsequently collapsed. Michael, Football Player, west point. First day of Ranger School at fort benning. Falls ill in his first day. He just completed a vigorous training session, gone to dinner when he fell out ill. Doug brenner, january 2017, university of oregon. There were trash cans lined up for the players to throw up in. Im sure so swollen i couldnt take off my own shirt without help. I could not even eat. So my objectives here in the next 2530 minutes we will talk about injury prevention, quickly identify some ideologies and focus on four entities that are exertional. Heatstroke, sickle cell trait, hypernatremia, with a specific focus on how to prevent these things from occurring. This is one of the leading models for sports injury prevention and as you see it as it moves around clockwise number one establish the extent of injury. Whats the perspective, severity, mortality . Try to establish how does this occur, what are the entry mechanisms. Entered is an injury prevention measure and then of course the soared and assess are we making a difference. What we try to layer on particularly military is prevention and the receipt three different forms of prevention, primary, make sure you dont give the flu. Secondary can interrupt or detect the disease before it becomes automatic. Check blood pressure. Tertiary come , limit the conses of symptomatic disease. Youre having a stroke to get to the Stroke Center to decrease the effects. This carries right honorable friend to sports. This was alluded to. You can see this is the largest cohort of death in athletes, and you see the 56 is cardiovascular that are others as we know derek sheely. What im going to talk about are the others, heatstroke, sickle cell traits. When we get back to cory stringer on the fateful day we all know this was exertional heat stroke. What we know about it . For us in military where we have 1 million men women under arms activeduty and reserve its a big deal. Big deal. Big numbers because we need a force that is ready. This was data from 2013, 324 heat strokes. We tend to know it tends to be the men over the women that have heatstroke to do one. Tends to be young, the young we predispose to these loads and in or sign up in the United States military asianpacific islanders at twice the rate of heatstroke and other cohorts. As dr. Hainline talked about these things are common. I quoted 325 in 2013 but in 2013 but we had 418 in 2015 and last year 470. Our numbers continue to climb but we dont have people dying because of some of the preventive measures im going to talk about. What about football its the sad read. Since 199554 reported Football Player but that was a heatstroke. 54. You take a look at it, its largely predictable. Most of these are in august, 60 . Onethird occurred more than two hours into the practice session. Most of us in room converted to. Interestingly enough, you take a look at the exertion heat illness rate in football, 11 times greater than all of the sports combined. Its football. You could argue this and i would make a strong stance you that exertional heat stroke is the most common cause of preventable nondramatic exertion sudden death american sports. Cardiac is very difficult to prevent. Heatstroke we should prevent. As is pointed out by mr. Sheely, we want investigations. The Israeli Defense defense fos at every single death excruciatingly and here in this publication that took a look at heatstroke deaths and they found two items present in 100 of cases. Number one, the physical effort was unmatched to physical fitness. You could predict it. And number two and most important, absence of proper medical training. Emergency action plan was not ready to go. Take a look at some the risk factors from the early model. Many of these were described by dr. Hainline. We talk about for physical fitness. Real problem with American Youth is they enter military service or the start these transition periods as dr. Hainline talked about. Lack of acclimatization. We talk about not only environmental acclimatization but also exercise acclimatization. We talk about obesity. Dr. Hainline talked about sleep. This is emerging as a powerful variable. In my expense as a military provider illness, how many kids are sick on that particular day, till the drill sergeant im up and get up to the company and feel very good. Or Marine Corps Marathon is coming up. Drugs i will talk about in a minute and the equipment. We take a look at what soldiers where this is not exactly something you have an easy time in the heat with. Also difficult time. Obesity, we have found this to be an extremely powerful risk factor for predicting heat illness. This one study done in fort bragg, overweight, three times more likely in the first 90 days of service to have exertional heat illness. We know this is a problem in the military. Take a look at football. We know a lot of the kids out there are running around are going to be very predictable for exertional heat illness. Beds come a lot of kids on medications meds. Medication allergies but anything that will affect your cardiac output, to sweat. These are Major Concerns that we need to be aware of as providers as these kids go forward, particularly and august 42 a days. What i would argue the most interesting to me as a military physician is this. Supplements, many of these do not have thirdparty certification to what you see is a soldier had an exertional death and asked the aniston and this is what they pull out of his locker. God knows what the combination is of this group of supplements. Primary prevention, what do we do . We want to make sure a place like the military or football training if you go off to aside that her condition is leveraged but acclimatization is hydration, cooling that we need to leverage primarily to keep kids cool. In the military, another thing mr. Schumer talk about, accountability. Theres accountability to the commanders to adhere to this table you see. What you see is a work rest water consumption table. Everyday temperatures measured. Work is classified and from that work within calculus appropriate work rest cycles and how much water should be provided. If you start of heat strokes and people are going down in large cohorts, the commanders will be held accountable. Did you follow the guidance to keep people safe sex data just produce a hydration guidelines. I was a part of this document in terms of making sure with adequate water but not too much. Very important point coming out of this document was to avoid fluid balance problems, drink when thirsty. That seemed to be the most powerful recommendation. For elite athletes they mean need more and more file into sports performed because drinking to thirst may not keep them at the edge. The most important thing is this right here. Individualization. Oftentimes we fall into the military or football team, one strategy for everybody. Thats not going to work because people are different and we need to recognize that. Dr. Hainline alluded to this ethically developed but this ts a high School Document to leverage acclimatization so we can change that trajectory of 54 deaths since 1995. Very carefully thoughtout, recognizing this vulnerable transition day one through five we see right here. No two days. No uniforms. Acta should not exceed three hours. You cannot walk too but you need a threehour period to recover. The cory institute is trying to propagate this across all states to ensure its safety of the show Football Players. Its also clear outside of football in athletic medicine literature this is from europe for one of want to really bring your attention to is that a conversation strategy here. Its one to two weeks. It takes time. Its not two days. You would have to be careful with this vulnerable transition period military with tremendous interest in keeping people cool because we need to keep people in the fight. Take a look youre just three little strategies not only keeping cool when battling prevent heat illness but may enhance performance. Simple things can you see a warrior and a humvee with a vacuum called twice for his hand. The military is very involved and look at the microclimate cooling devices all the way down to the underwear. And simple things like slush is what many foreign militaries will leverage to try to keep people cool so they can go forward and exercise. Very important, sometimes as physicians we need to jump in and say not going to be a good day. This is a sign from the chicago marathon back in i believe 1996 race overcome three hours. They had so many strokes at the time and ran out of water and had to stop the race. Two years ago in washington the army ten miles the race had to stop as well, had 30 heat strokes which was unprecedented. This is a paper that says theres a way to determine a do not start temperature that maybe we live to fight another day. This is what medical directors, physicians need to jump in, follow the data as dr. Hainline talked about, develop plans that say maybe we go tomorrow. Maybe we keep you in a fight for a future marathon. Secondary prevention, i was also moved by mr. Healy, this is what we leverage the military were so misses johnny does not look right. Bring them to a medic. Thats perhaps our most important sector prevention measure. Looking at signal cases when you see things pop up on one particular to our unit. They are having a bad trend over here. Something stuck right. The other thing we do in the military is with leverage what we call heat dumping. Every opportunity where kids are hot come , here you see in the l again leveraging a hand coding device. In the military at fort benning we leverage showers, cool shows, run kids do these all the time. The other thing we do is we now have these cooling systems filled with cold water and the skids moved from training site they rode their sleeves, put their arms in to keep themselves cool throughout. Tertiary prevention means you are ready. When someone drops Everybody Knows the plan. Here you see a picture down at fort benning. We have barrels filled with cold ice sheets so if a soldier goes down, this drill sergeant knows wrap this kid in this ice brito and call 9 11. This intervention alone will help say that young mans life. The other thing in addition to this drill sergeant being in action is we need Rapid Intervention as dr. Hainline alluded to being prepared. Military can we use little different technique. We have a governing here suspended over ice water and would bring up and over to complete cold water immersion. Just a brief picture here from the Marine Corps Marathon. Get out of the way. Get out, get out, get out. A little loud but that being said, its a heat attack. Its a heat attack. If we dont act a young man will die. Thats a team that is hactivist and ready to go. They had 100 heat strokes last summer. Everybody walks away because theres a good plan and execute it and they practice it. Field treatment here very common. Dr. Hainline talked about it, emergent cooling. Were preparing to treat onsite with preparations for transfer but its all about a plan, attics the plan and executing the plan. They avoid them dale lloyd was thought to be a benign condition. However, its very clear in the literature. This is the american medical journal of medicine. Here you see faces of Nine AmericanFootball Players who all died as a result of sickle cell trait associated crisis. The military said the publication 1987 establishes very clear if youre africanamerican and her sickle cell trait positive you have nearly 30 times the risk of sudden death event in the first year compared to being africanamerican and sickle cell trait negative. University of washington looked at a cohort and established or also established this risk is about the same. Africanamerican sickle cell trait positive have higher relative risk of sudden cardiac death. She determine if your African American sickle cell trait Football Player, you have an absolute risk of one in in 185f sudden death in. Going back to the original construct, sickle cell trait falsity of the category. Dr. Emery talked about lightning strikes thats commonly using that analogy but the sickle cell trait rooted confiscations and deaths are rather rare. We need to have the right balance here in the right narrative when we committed to africanamerican athletes on what is the risk and what is not the risks . What do we know about these deaths . Most electron from case reports as an ncaa athlete who died in 2014 and an offseason training work out at cal berkeley. Generally unconditional military recruits or deconditioned athletes in that transition period thats when this generally happens. Repeated intense bows limited time for recovery and unlike a cardiac death most of these deaths are conscious. The athlete will go done complaining of weakness, i cant walk there still alert at least initially. This is a very detailed slide taking a look at how does sickle cell trait cause death . In many thoughts theres a local environment here, hypoxia acidosis, increased interest that may cause signaling with an explosive rhabdomyolsis but this is a hypothesis being worked out but that is the leading thought somehow we are precipitating a sickle cell trait crisis, excuse me, a sickle crisis in someone who is sickle cell trait. This is controversial. A lot of different thoughts. He believes its all a all the hydration, hydration is a key variable in leading to the sickle cell trait crisis. Doctor iker was in oklahoma, you see is, too, he is no more a trigger for exertional sickly dentist alta to come athlete, or a reckless coach. Truly believes intensity is the key variable. As dr. Hainline alluded to wear very interested in this, very interested in the genomics. Because i know the mr. Speaker sickle cell trait positive africanamerican your risk of dying in the first year is one in 3000. Im interested as i exploited dr. Hainline in the 2000, 999 what exact same boat as to why they dont die. That is interesting to us and my bottom line up front and what we are trying to uncover and explore is that maybe all sickle cell trait athletes are the same. There might be Something Different in some that predisposes you might be able to find it, stratus report and provide better advice. Terms of primary president xis dr. Hainline talked about their screen out division thats recommended. You can wave out if you want different athlete but screening is mandated. The dilemma for physicians is just as dr. Hainline came out in the ncaa recommends screening there some people like the American Society of hematology the came up and said we opposed this screening. Your screen for genetic variation. This has the potential, student athletes, and may create a false narrative. This is a tough issue especially when youre getting outside of the ncaa with High School Athletes or athletes in the military on what to do. But most and this is a guidance on the ncaa, this this is a con sense kind i give also to parents of high school. Ive emboldened some of the key things, slow gradual preseason conditioning. Again recognizing that transition period the excuse from a performance test such as serial sprint is a saw in darrell lloyd. Stay well hydrated. Refrain if youre ill and seek prompt medical care. It speaks to universal common sense guidelines and a clear recognition of transition period secondary prevention, and again dr. Hainline new document emphasizes all these points, or have a punitive exercise. This is where people get naked trouble. Recognize and athlete who are struggling. As we heard with ms. Sheely this morning and when they are down, to help them up your most importantly. And finally develop adequate Emergency Action plan that is rehearsed, practiced and ready to go. Sector prevention includes hydration. My read of the literature, the single most important thing in African American athletes to do in addition to harmonization is leverage hydration and stay hydrated. Tertiary prevention, war fighters, we give a brief to edwin come in they are aware of the risk but most important we have detailed Emergency Action plan on what to do if an athlete goes down and everybody from a coach to the trainer, drill sergeant is aware of this so we can execute it weekly. This is just an education tool ill show you quickly to share this with dr. Hainline but with different beta tapes we produce in the department of defense to give to the contrary, tradespeople, to the doctors were going to mansion these problems come into the soldiers. I wont belabor this in the essence of time but were trying to produce these tools to get them to the right people. Bottom line, try to be prepared. Michae