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February 20, 2003
Under The Knife
The Dangers of Heatstroke
On Sunday, heat illness claimed yet another victim in the world of sport, 23-year-old Oriole pitching prospect Steve Bechler. According to reports, he was a little over halfway through a run when he stopped and leaned against a fence. He was observed to be pale, disoriented and complained of nausea. He was taken to the clubhouse by the Orioles medical staff and subsequently sent by ambulance to a hospital, where his condition continued to deteriorate and he died the next morning. The preliminary cause of death was listed as "multiple system organ failure caused by heatstroke."
Any time a young person dies, it is a tragedy. In Bechler's case, he leaves a young wife expecting their first child in a little over a month.
Steve Bechler wanted to be a professional baseball player because it was what he loved. He had spent five years in the minor leagues, got promoted to the Orioles' roster at the end of the 2002 season, and pitched in the major leagues. That is the dream of any professional baseball player: to make it to the majors. And once a player gets there, he wants to stay there.
Bechler was a promising pitching prospect for the Orioles, but probably would have not been on their roster at the start of the 2003 regular season. He was likely ticketed for Triple-A Ottawa, where he would once again hope to impress the Orioles with his performance. As Spring Training for pitchers and catchers began last week, Bechler had another opportunity to impress those who evaluate talent for the major league team. On Saturday, Mike Hargrove reportedly pulled Bechler out of a run during a "circuit training" drill because he was "laboring and sweating profusely." It is unknown what, if any, treatment he received between that time and when he pulled up during the run on Sunday.
There are a multitude of things that we don't know about Bechler's condition. What we do know is that healthy, young, athletic individuals do not die of natural causes. We know that Bechler passed a pre-participation screening exam, conducted by a licensed physician, prior to beginning Spring Training. We also know that Bechler had undergone an EKG in 1999 that indicated no cardiac pathology.
Why, then, did Bechler die of heatstroke, during a half-mile run, in his first week in Spring Training? An autopsy is currently being conducted which will provide more scientific data, but the entire cause of Bechler's death may never be known.
We do know that Bechler had been battling a weight problem for his entire professional career. His target weight for reporting to Spring Training had been set at 220 pounds; instead, he reported at 242 pounds. Research--and common sense--tells us that the greater the body mass and body surface, the more at risk one becomes for a heat illness. Bechler reportedly took a dietary supplement containing ephedrine in an attempt to lose weight. We know that he had previous heat-related problems, as reported by his parents, but not in his pre-screening. There is also the issue of acclimatization to be considered. Bechler had been in Spring Training in Fort Lauderdale for less than a week. The temperature was 81 degrees and the humidity was 74% when Bechler pulled up during Sunday's half-mile run. One must remember that Bechler was from Oregon, where temperatures and humidity levels during the past several months have been substantially lower than those to which he was exposed in Florida.
Let's examine the risk factors for heatstroke. We spoke with nationally renowned heat illness expert Dr. Douglas Casa of the University of Connecticut. Dr. Casa is the co-author of the National Athletic Trainers Association's Position Statement on Exertional Heat Illness. He detailed many factors that affect heat illness for me. These include overexertion, temperature, humidity, sun exposure, occlusive clothing (it is not unusual for individuals trying to lose weight to exercise while wearing a rubber or plastic jacket), dehydration, lack of acclimatization, concurrent illness such as an upper respiratory infection, and the use of any substance containing ephedrine.
The most important of these, he said, is humidity. "When you're looking at heat load, 70% of it is humidity. It's possible to have a relatively low temperature, but high humidity and be at a significant risk for heat illness." We asked if this put teams training in humid Florida at more of a risk than teams in arid Arizona. "I've never seen any data on that, but it makes sense," he replied.
Heatstroke has been recognized as a true medical emergency. It produces a marked hyperthermia that can cause widespread cellular damage. As stated above, the larger an individual is, the greater his exposure to heat illness will be. Unfortunately, it is not uncommon to hear of heatstroke fatalities at the start of preseason football, in hot, humid areas of the country. Professional football player Korey Stringer suffered a fatal heatstroke during football training camp with the Minnesota Vikings just last year. Normally, an athlete is at risk for the exertional type of heatstroke, where the exogenous heat load (determined by air temperature, humidity and solar radiation) combines with the athlete's metabolism and muscle action to overwhelm the body's thermoregulatory system, creating an uncompensated heat stress. The evaluation at the practice site is usually based on changes in mental status (confusion, disorientation) and a core temperature greater than 105 degrees Fahrenheit. Of these risk factors, the ones that are within the athlete's control are the lack of acclimatization, physical fitness level, overzealous performance (competing above the individual's current level of fitness or ability), dehydration, and the use of substances containing ephedrine.
Acclimatization is the process by which the human body becomes accustomed to physical activity in a new environment, normally one that is hotter and more humid. If the desired level of physical activity is intense, then the acclimatization process can take up to 14 days. The first stage of acclimatization (days one through five) involve improved control of cardiovascular function, including expanded plasma volume, reduced heart rate, and autonomic nervous system habituation, which serves to redirect cardiac output to skin capillary beds and active muscle. In the intermediate stage (days six through eight), the body begins to increase retention of sodium chloride (salt--a factor in retention of electrolyte balance) and a 15-20% reduction in exercising heart rate is accomplished. During the final phase (days nine through 14), the plasma volume expansion begins to decay and is replaced by the longer lasting reduction in skin blood flow that serves to increase central blood volume. Once this has been accomplished, the human body has made the adaptations necessary for healthy performance in the new environment.
Acclimatization should be a scientific process, because we are dealing with the physiology of the human body. Larger athletes--especially those whose cardiovascular fitness level is questionable--and overweight athletes will not acclimatize as rapidly as smaller, more fit individuals. Research has indicated that activity level should be gradually increased during the acclimatization process, limiting strenuous activity to 60-90 minutes per day during the early stages, and that it is best to exercise during the morning or evening hours, when the temperature and humidity are lower than in the heat of mid-day.
Dehydration is another important aspect in heat illness, especially with larger athletes. The key factors are monitoring weight loss, monitoring hydration, and monitoring core body (rectal) temperature. Weight loss is normally monitored by the use of weight charts. The athlete is weighed prior to activity and after activity. The weights are recorded on a chart so that the team physician and certified athletic trainer can determine the athlete's exertion and hydration needs. Loss of as little as 2% of total body weight can lead to premature fatigue and impair mental status; losses greater than 5% can put the athlete at serious risk for heat illness.
Two hours before activity begins, an athlete should drink at least 16 ounces of fluid. During exercise, an athlete should drink at least 10 ounces of fluid every 10 or 20 minutes. After activity, the athlete should drink 24 ounces of fluid for every pound of body weight lost through sweat in the activity.
In Bechler's case, it has been reported that the activity consisted of 12-minute circuit exercise bouts with a water break between each bout of exercise. This would seem to be sufficient if he, in fact, drank a sufficient amount of water at each break. Using the accepted medical standards, a man his size should consume approximately 144 ounces of fluid (12+ Cups) during a two-hour period of intense physical activity. This is why water breaks need to be monitored. The thirst reflex cannot be depended upon because it normally leads to ingestion of only 50% of the actual fluid that our body needs during exertional activity.
As to the types of fluids needed for replacement, there are many. Obviously coffee and beer should be avoided because they act as a diuretic, causing additional fluid loss. Water is very good up to the point when the body develops a deficiency in carbohydrate stores and sodium. This author receives no stipend from Gatorade, but has used their product for hydration purposes while working with high school, collegiate and professional athletes with excellent results. Also, their Sports Sciences division is doing some of the top research in the field of hydration and heat injury prevention.
Concurrent illness can play a factor in heat illness. Nobody wants to go on "sick call" because they have slight cold or minor influenza symptoms when they are trying to impress major league administrators (managers, coaches, etc). However, symptoms such as fever and diarrhea can have serious effects on dehydration of the human body and put it at greater risk during physical activity in hot and humid conditions. It should be noted that the southeast United States has recently had a virtual epidemic of these types of influenza symptoms, resulting in some cases of school attendance being 50% or less.
Baseball is sometimes reluctant to let go of some traditions, despite scientific findings. The use of occlusive clothing in the form of "sweat jackets" made of rubber or vinyl has been a mainstay around baseball training camps for years. The idea behind their use is that the athlete will sweat more during activity and therefore lose weight. That much is true. However, the weight being lost is the result of water loss, and that can lead to dehydration. Also, any weight lost in this manner will be regained as soon as the body is rehydrated. Human body heat increases during exercise, but the body is normally able to dissipate heat and cool itself through the process of sweat evaporation. If this heat is trapped under an occlusive garment, then evaporation and normal heat dissipation cannot occur, therefore interfering with the body's thermoregulatory system and putting the athlete at risk for heat illnesses. We truly enjoy going to Florida or Arizona to watch Spring Training, but we cringe every time we see an athlete running in the Florida heat and humidity wearing one of these "sweat jackets."
Preliminary autopsy reports show that Bechler was taking Xenedrine RFA-1, a thermogenic weight loss product that contains ephedrine. Worse, it appears that Bechler was taking 50% more than the recommended dose. Ephedrine is commonly found in supplements that purport to help the user lose weight and/or gain energy. Creatine is commonly used by athletes who want to increase muscle mass and strength. The use of these substances is not banned by Major League Baseball or addressed in the drug testing section of the new CBA. Ephedrine, also marketed as ma huang, is found in many supplements. It is a stimulant that has a molecular structure similar to amphetamine. Ephedrine has been known to produce arrhythmias, tachycardia, palpitations, hypertension, respiratory depression, and heart attacks. Obviously none of these adverse effects should make this substance a part of the dietary or training regimen of someone involved in intense physical activity. The use of creatine has sparked controversy in the world of sports. What is known about this substance is that users need to be aware of maintaining proper hydration to avoid adverse side effects.
The pre-participation physical screening given to Bechler when he reported for Spring Training will probably come under some scrutiny. It probably should not. It is easy to say that whatever caused someone's death today should have been picked up on a physical examination administered a week ago, but that is certainly not always the case. In this instance, qualified medical personnel administered the pre-participation screening exam. Usually, this exam consists of height and weight measurement, body composition measurements, orthopedic screening for joint conditions, stethoscopic examination of heart and lungs, general medical screening, and a review of the athlete's medical history. Athletes who want to make a team or move up in the organization are often hesitant to mention what they consider to be minor medical problems. In an interview in the Baltimore Sun, Orioles team physician William Goldiner said "I didn't know that [Bechler] had heat-related problems [in high school] until this happened. But let's say he had told me that--I would not have made any special changes in his routine versus anybody else's." Although we do not know this for a fact, it is my guess that the pre-participation physical screening exam done by the Orioles staff is the equivalent of those given by any other major league baseball team.
However, we should learn from tragedy. One of the problems with a pre-participation screening exam is that it is done "at rest." Athletes do not perform "at rest." If non-obvious medical conditions are going to adversely affect the athlete, it is most likely going to occur during periods of exertion. A stress EKG (treadmill test) would obviously have given more information regarding the functioning of the athlete's heart and lungs and about his cardiovascular fitness level. So, why was this not done, especially with the memory of Darryl Kile so fresh in the consciousness of baseball?
The reason most likely is that a large number of athletes were examined in a relatively short period of time. It was reported that Bechler's pre-participation exam lasted 20 minutes. If the stress EKG had been included in the screening exam, the total exam time would probably have been close to one hour per athlete. Despite the added time needed, a more thorough exam would have given the Orioles medical staff a lot more information with which to work. Bechler had an EKG in 1999. We do not have the information as to whether it was a resting or stress EKG, but in either case, it is highly possible that his medical condition has changed in the last four years, especially if he had gained a significant amount of weight during that time. We would think that, given the large monetary investments in professional athletes, it would serve teams' interests to require an annual stress EKG of every player. Professional sports are certainly not alone in this issue. There are high school sport associations in this country that only require one pre-participation screening for an athlete during his/her entire high school career. If one imagines all the changes that can take place during that period of time, then it is extremely easy to understand why some of these young athletes are at extreme risk when competing.
The final issue to be considered in the case of Bechler's death is overzealousness on the part of the athlete. His body had told him the day before when he had to be pulled out of the run that he was not yet fully acclimatized, and that his fitness level was not where it should be for him to be doing the intense physical activity that was part of Spring Training. We have no doubt that Steve pushed himself because he wanted to make the team or at least impress Oriole management so he'd be recalled to the big club later in the year. We don't know if he properly rehydrated himself after the episode on Saturday. We don't know whether in fact he suffered some form of heat illness, such as heat exhaustion on Saturday. But we do know that heat illness can be progressive and that each heat injury episode can damage the body's thermoregulatory system, thus making it more susceptible to subsequent heat illness. We don't know how Bechler felt when he woke up on Sunday morning; maybe he shouldn't have practiced that day, but he wanted to make the team, so there was no way he was going to voluntarily miss a practice. Let's hope that decision is not what caused him to miss the rest of his life.
A key that seems to be missed in all the coverage is how Bechler was treated in the "golden hour" following the onset of heatstroke. We know that his problem was observed immediately--and that within minutes, the medical staff was attending to him and transporting him to the training room. We do not know, however, what steps they followed. According to Dr. Casa, the proper treatment would be to cool the athlete "by any means necessary." The easiest method would be to immerse the athlete in ice water. "Many teams have a simple Rubbermaid tub and ice near the field," said Dr. Casa. "At road races, we've had people literally walk away minutes after treatment." Many trainers, including some we spoke to, worried that an athlete being immersed in cold water would go into shock. Dr. Casa says this should not be a concern. "It's never happened. It's so much more important to cool the athlete as rapidly as possible, but we have no recorded instances of [shock] occurring in this manner."
All of the above is a conjecture based on sports medicine as it is understood today. It has come a long way in the past 20 years thanks to research, but it still has a long way to go before we have all the information available to make athletic competition as safe as possible. There will always be an element of risk because risk is inherent in sport. If we had all the answers right now, it would be too late to help Steve Bechler. With that being said, hopefully we will be able to prevent this tragedy from occurring again. There has reportedly only been one death in major league baseball attributable to heat illness--Bechler's--but that is one too many. Any death is a shame, but it is left to those of us left behind to act. Perhaps baseball will take more notice of educators like Dr. Casa and his work in the field of exertional heat illness as well as taking the simple step of controlling substances such as ephedrine.
This article was reviewed for accuracy by Douglas Casa, Ph.D., ATC, one of the top educators in the world on exertional heat illness, and by the UTK Medical Advisory Board.