MAJOR ATHLETIC ISSUES - diving accidents

HEAT STROKE

Almost eight million boys and girls participate in secondary school sports. Given the number of participants, playing sports is relatively safe and beneficial in the development of an individual physically, mentally and socially. However, along with their competitive spirit comes the risk of injury.

The latest research indicates the leading causes of death in high school sports are sudden cardiac arrest, exertional heat stroke, traumatic head injuries and sickle cell complications. Although all athletes are not immune to injury, those stepping onto the playing field with pre-existing conditions may increase their risk for sustaining certain injuries. One such risk is exertional heat stroke (EHS) in those athletes with attention deficit hyperactivity disorder (ADHD).

EHS is non-discriminatory as it can occur with male or female athletes, football or field hockey and freshmen or seniors. A combination of poor environmental conditions creates the perfect storm for EHS. However, for those with ADHD, a warm environment may be the sole variable putting those athletes at risk.

As a result, environmental conditions must be monitored through Wet Bulb Globe Temperature (WBGT) versus the Heat Index. Since the WBGT measures ambient temperature, relative humidity, radiant heat from the sun and wind speed, it is most appropriate to use in athletics.

The Heat Index is a measurement of ambient temperatures and relative humidity while resting in the shade. It is intended to provide outdoor restrictions for the elderly and adolescents during times of elevated temperatures and not relevant in an athletic setting.

Many ADHD athletes are managed with prescription medications that permit the brain to reach a balance by increasing cognitive activity to bring executive functioning up to normal levels, or increasing inhibitory activity to bring impulsivity down to normal levels. Regardless of the approach, certain stimulants are usually the treating physician’s medication of choice. Also, ADHD is a “2 for 1” disorder with 20 to 30 percent of adolescents having comorbid conditions such as depression, bipolar, OCD, ODD, anxiety and/or Tourette syndrome. These disorders are commonly treated with some tricyclic anti-depressants.

Athletic trainers and coaches must remember that secondary school athletes are students first. Any prescribed pharmacological treatments are important for both their classroom and social functioning; however, these medications may also put those athletes at risk for a heat-related illness.

Studies show an increase in core temperature in those individuals taking a stimulant medication. Initially, athletes may not exhibit any obvious signs of fatigue due to the nature of the drug. They will continue participating at a high intensity in the heat, increasing the risk of their core temperature reaching >40 C (>104F) for an extended period of time.

Equally important, athletes treated with anti-depressants may experience dysfunction with the body’s sweating mechanism; therefore, decreasing the body’s ability to effectively cool when exercising. Unfortunately, not until ADHD athletes reach the stage of collapse do coaches become aware of this true emergent situation.

The risk of ADHD athletes falling victim to EHS can be significantly reduced through proper management by the athletic trainer and coaching staff. Prior to the sports season, the school nurse should provide the athletic trainer and the team’s coach with a list of medical considerations of the athletes on that team. Not only does this help identify those athletes with pre-existing conditions related to cardiac, sickle cell, asthma and seizures, but it also informs the staff of those athletes taking medications for ADHD.

In order to maintain confidentiality, it is advisable that the athletic trainer and head coach meet with the ADHD athletes individually and privately in order to discuss the signs and symptoms of heat illness and its management on the playing field. Adequate and unlimited hydration should be readily available. A “cooling station” in a shaded area should be easily accessible. It is recommended the cooling station contain an immersion tub with cool water, coolers of ice and wet towels.

Exertional heat-related deaths in ADHD athletes are 100 percent survivable when the appropriate management and treatment measures are followed. First and foremost, an approachable, non-intimidating atmosphere must be established by the head coach. ADHD athletes should feel comfortable expressing the feeling of any heat-related signs or symptoms when playing in the heat.

Continued surveillance of ADHD athletes by the athletic trainer and coaching staff during practices and games decreases the risk of these athletes suffering from a catastrophic heat-related illness. Let’s face it, when playing sports, we all want to win. But when parents sign the consent to permit their son or daughter to participate in interscholastic athletics, they expect the athletic trainer and the coach to ensure their health and safety is held in the highest regard.

AT THE BEACH / TOODLERS:

Heat stroke (sometimes called “sunstroke”) is a condition that happens when someone gets overheated. It can be life threatening because the body’s temperature continues to go up and the body is unable to cool itself anymore.

Babies and toddlers are especially prone to having problems with heat stroke since they are not as efficient with regulating their temperature yet and especially babies can’t actually tell you that they are way too warm. It can happen in when spending time in hot weather if your infant is outside for too long; it can occur riding in a car that is warm or even by being overdressed in the stroller.

It is very important that you know how to prevent, spot, and treat heat stroke in babies and toddlers to avoid serious medical issues.

Exertional heat injuries

 Exertional heat injuries are known to affect marathoners and army recruits under hot and humid environmental conditions [1,2]. This occurs when heat production exceeds the body's ability to dissipate heat. Since peripheral vasodilation and sweating can dramatically increase heat loss, the lack of these physiological responses seriously predisposes those with these conditions to exertional heat injuries. The authors report a unique case of a female marathon participant who suffered exertional heat stroke possibly caused by her inability to sweat over a large surface area of her body and thus accumulating heat rapidly. 

Swimming Pool Accident Statistics

 According to Shepherd Center, diving makes the list of the top five causes of spinal cord injuries with paralysis. 89% of individuals who get hurt diving are male and 11% are female.  Most individuals who are injured are between 20 and 29 years old. 

There are multiple ways for a dive to end in injury or paralysis based on the location and structure of the spinal cord. The severity of disability depends on the level of the spinal cord where the damage occurs.

The vertebrae of the spine, separated by intervertebral fibrous discs, protects the nervous system’s spinal cord. It is possible to damage the spinal cord by injuring the vertebrae and discs or by injuring the spinal cord itself. “Severe damage to the cord and nerves emerging from the vertebral column will cause paralysis,” reported WHO.

Florida is a popular tourist destination that attracts people from around the world. In fact, the state hit new tourism high with 120 million visitors in 2017. However, many of these tourists are unfamiliar with the state’s landscape—one that varies by region—which can lead to devastating swimming & diving injuries.

This year, Long Island resident Andrew Gallo sued the Ritz Carlton for personal injury damages with the help of Stuart Grossman, leading personal injury and medical malpractice lawyer.

Gallo was staying at the Ritz Carlton South Beach hotel while visiting Miami for the first time. During his stay at the hotel, he decided to go for a swim at the hotel’s “Ritz Beach,” a location heavily advertised as a chief amenity. Patrons are invited to lounge at the private beach—which is exclusive to hotel guests only—and enter the ocean at their leisure.

Unfamiliar with the water’s depth at this location, Gallo dove into the water, injuring his head on the shore’s shallow bottom. He was unaware that further out in the water, the depth changes and becomes shallower due to a sandbar-like effect. The impact caused serious spinal cord injury, leaving him a permanent quadriplegic. He now needs extensive medical care for the remainder of his life.

While this particular case is ongoing, our team has significant experience with similar swimming & diving injury cases. For example, in a recent Key West case, we represented a tourist who was permanently paralyzed after jumping into the ocean at low tide. He, too, was unfamiliar with the dangers of Florida’s waters and now needs lifelong care.  You can view the details of this swimming & diving injury case and its resolution here.

These cases aren’t uncommon, which is why Stuart Grossman and Billy Mulligan of Grossman Roth Yaffa Cohen have called for mandatory ordinances across businesses and establishments statewide, warning tourists of the changing condition of Florida’s waters. You can view their op-ed in the Daily Business Review here.

• Drowning is the #2 cause of accident-related deaths in children ages 14 and under.
• Among 1,000 adults surveyed, 50% said they have had at least one drowning scare in their lifetime. 2/3 of that group says the near-drowning event occurred between the age of 5 and 15.
• In a recent survey of families with young children, almost 90% planned to be in the water during the summer months, while nearly 50% of them had plans to swim where there was no lifeguard.
• 19% of drowning deaths involving children occur in public pools with certified lifeguards present.
• One-third of adults do not realize that staying within arms’ reach of a child is much safer than using “floaties” or other similar swim-assist devices alone.
• The place where drowning is likely to occur changes with age. About 60% of deaths among children occur in swimming pools. Children ages 1 to 4 years most often drown in home pools.
• Of children ages 4 and under who drown, 70% are in the care of one or both parents at the time of the drowning and 75% are missing from sight for five minutes or less.

Many assume that drowning persons are easy to identify or exhibit obvious signs of distress. Instead, people tend to drown quietly and quickly. Children and adults are rarely able to call out or wave their arms when they are in distress in the water, and can submerge in 20 to 60 seconds.

Diving Accident Statistics

• Less than 10% if swimming pool diving injuries involve a diving board, most result from running and or misjudged distances.
• Zero above-ground pools are safe for diving. The American Red Cross recommends a minimum of 9 feet of water depth for head first dives including dives from pool decks. Many in-ground pools are 10 feet deep in the diving end. “No Diving” signs should be placed around all above ground pools.
• Over 50% of diving accidents involve the use of alcohol.
• 57.2% of all pool diving accidents occur in water 4 feet deep or less (standard above-ground pool depth), while only 4.8% of swimming pool diving accidents occur in water at least 8 feet deep. Not only should you avoid diving in all above ground pools, but you should never dive in the shallow end or from the sides of in ground pools.
• According to the American Institutes for Research, 16.8% of all diving accidents occurred from attempting an unusual dive or trick. Trick dives are hazardous and should not be attempted in a residential pool.

One hot Sunday afternoon, a family was enjoying a leisurely barbeque around their new backyard swimming pool. The children played a game of tag in the pool, while the father cooked on the grill. The mother was carefully watching the children as she sat along the pool edge.

Suddenly, the 12-year-old boy quickly climbed out of the pool, in order to avoid being tagged, and immediately dove back in. In the boy’s effort to keep away from his sister, who was trying to tag him, he dove too deeply into the water and struck his head on the pool’s bottom. The child floated motionless to the water’s surface. The mother quickly jumped into the pool and supported the boy by placing one arm under the child’s neck, and the other arm under the child’s knees. She then lifted the boy onto the pool deck.

In the mother’s attempt to rescue her child, she actually further aggravated a spinal cord injury that occurred when the boy dove into the water and struck his head on the pool’s bottom.

Each year, doctors identify and treat approximately 10,000 new spinal cord injuries in this country. The average age of onset is 28.7, and the most common age is 19. Fifty percent of the injuries occur in the 15- to 24-year age group. Eighty-two percent of all spinal cord injuries occur in males.

The following statistics represent the etiologic causes of spinal cord injury in this country: Motor Vehicle 36.5%; Falls 15.8%; Gunshot 11.6%; Diving 10.6%; Other Causes 24.5%.

The major cause of these devastating traumatic injuries is, as you probably expected, motor vehicle accidents. However, the second leading cause are those injuries resulting from sports and recreation activities. Water-related activities are the number one cause of spinal cord injuries resulting from sports and recreation activities.

Each year, approximately 13,000 diving-board-related injuries are sufficiently serious to be brought to hospital emergency rooms; diving accidents cause approximately 800 spinal cord injuries. The Consumer Product Safety Commission (CPSC) estimates that this is a yearly occurrence.

According to the CPSC, “… one of the major accident patterns associated with swimming pools was striking the bottom or sides of the pool because of insufficient depth for diving or sliding….” Further, “… in addition to striking the bottom of the pool, people are injured when they hit protruding waterpipes, ladders, or other objects in the pool.”

Diving should be strictly prohibited in shallow water. Over half of the swimming pools in the United States are above-ground vinyl swimming pools, most of which have a constant depth of three to three and-one-half feet. In order to gain entrance into a pool of this type, most pools provide a ladder or platform. Many injuries occur each year when children or adults attempt to dive into the pool from these ladders and platforms.

Remember: this Fact: 

Diving is one of the first causes of swimming-related head and neck injuries. Those injuries occur when swimmers dive in shallow or unfamiliar waters or have improper diving technique. This leads to head-first collisions with the ground, pool walls or invisible obstacles lurking in the water.

Such collisions can lead to brain injuries and damage the cervical spine and the spinal cord. These injuries can be severe and even life-threatening. That’s why you should never dive in shallow water (less than 12 foot deep) or unfamiliar bodies of water.

• Bring supplies to help you and others stay healthy—for example, masks (bring extra), hand sanitizer with at least 60% alcohol, broad spectrum sunscreen with SPF 15 or higher, and drinking water.
• Prioritize participating in outdoor activities over indoor activities and stay within your local area as much as possible.
  • If using an indoor facility, allow previous groups to leave the facility before entering with your team. If possible, allow time for cleaning and/or disinfecting.
• Check the league’s COVID-19 prevention practices before you go to make sure they have steps in place to prevent the spread of the virus.
• If you are at an increased risk for severe illness or have existing health conditions, take extra precautions and preventive actions during the activity or choose individual or at-home activities. 
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REMEMBER: 

All patients should be symptom free for at least 14 days prior to any sports participation.

1. Asymptomatic patients (tested positive or are presumed positive)
   Should refrain from sports participation for at least 14 days from known infection. If asymptomatic, may return to sports following evaluation by pediatrician. Pediatrician evaluation should include cardiac-related questions including evaluation for history of syncope, near syncope, dizziness, angina, or palpitations during exercise. Additionally, physical exam should include evaluation of blood pressure and resting heart rate, as well as auscultation for presence of arrhythmia, new-onset murmur, or other abnormal cardiac sounds.
   • Cardiology evaluation should be sought if pediatrician feels this is warranted. 

1. Pediatric patients with moderate symptoms (fever, cough, etc/bedrest without hospitalization)
   Should refrain from sports until symptom free for 14 days. Can return to play after cardiac evaluation with ECG prior to sports clearance. May require further testing (echocardiogram, troponin, etc.) based on cardiac evaluation and ECG results.
2. Pediatric patients with severe symptoms (required hospitalization, especially if suspected multisystem inflammatory syndrome (MIS-C), abnormal cardiac testing during illness) - Recommendation is to follow more conservative myocarditis return to play guidelines. 
   • 3-6 months of recovery time prior to returning to exertional activities and sports.
   • Close monitoring with resumption of activities only after cardiac evaluation and testing (ECG, echocardiogram, 24-hour Holter monitor, stress testing, possible cardiac MRI) has normalized.
   • Patients may require more frequent cardiac evaluations and for a more prolonged period of time both prior to and during their return to sports and physical activities.