It is my honor to introduce our next speaker colonel francis oconnor, m. D. Who is the professor and chair of military a friend medicine, took me around and it is a great place where we have training, medical training for those who be serving and providing service to men and women who serve our country. Trait he created a medical study on trying to understand sickle cell traits. He has been a mentor and a friend to john and me and doctors others. Thank you for coming here today. Thank you. , i amn honor to be here mrs. Shealy listening to your words and your passion. I will not forget. Im going to be moving away from cardiac and talking about exertional illness. I am with the department of defense and all the opinions i. Ave today are those of myself dozen one in minnesota in the midwest heat index 110,s junior vomited three times, complained of dizziness and be grand and be grand breathing heavily. 2006 Football Player collapsed on the field after exerting himself in. Early on he was showing to stress and difficulty breathing, complaining of tightness and having trouble standing and collapse. Michael, Football Player at west point. First day of Ranger School in fort benning falls ill on his first day. He adjusts completed a Training Session when he fell ill. Another Football Player, january 2017. Couldnt move his arms up to the second day. I could not even each. Is we wille seer talk a little bit about injury prevention, and focus on four entities. Heat stroke, sickle cell trait, hypernatremia and. With a specific focus on how we prevent these things. This is one of the leading models for intervention. Establish the extent of the injury. , try tothe severity establish how did this occur when injury mechanism introduce an injury and fastforward are we making a difference. On we seey to layer three different forms of prevention, primary, immunization secondary detective disease, check the Blood Pressure to identify hypertension, limit the consequences of tertiary disease. This carries right over into sports. This is alluded to and the athletes. Death and you see 56 is cardiovascular but there are others, blunt trauma, and the others. Heat stroke, sickle cell trait. Back to corey stringer on that fateful day we all know this was exertional heat stroke. We haven the military one million men and women active duty and reserves are at it is a big deal. The numbers. When we take a look at the numbers this is from 2013, 324 heat strokes. It tends to be the men over the women that have heat stroke, to toone. Pacificilitary asian islanders have twice the rate of stroke she strike than others. As the doctor talked about these things are common. 2014 and last year 470. Our numbers continue to climb but we dont have people dying because of some of these preventive measures. 1995 54 reported Football Players as a result of heat stroke. Most of these are in august, 60 . If you look at the exertion for football in 11 times greater than all other sports combined. This and exertion in mostoke is the most sports. Heat stroke we should prevent death. Shealyplayed out by mr. The Israeli Defense force looked ,t every single test death they found two items in 100 of the cases. Unmatched,fort was and absence of proper medical triage. Emergency was not ready to go. Risk factors from that early model, many of these were described by the doctor. Poor physical fitness. Transitionthese not only environment but physical. The doctor also talked about sleep. This is a powerful variable. Illness, how many kids are sick on that particular day, cap tilde drill sergeant i dont feel well. You can choose the day you are going to exercise. Drugs, i will talk about in a minute and the equipment. We take a look at what soldiers where. This is not exactly that they have an easy time in the heat with. Obesity, we have found this to be a powerful risk factor. This study was done by four bright, overweight three times more likely in the first 90 days of service. We know this is a problem in the military. Looking at football, a lot of kids running around are going to exertion. A lot of kids are on medication, medication for allergies, anything that will affect your , theseoutput, your sweat are Major Concerns that they need to be aware of as providers. Particularly in august for 2adays. Supplements, many of these, this is say soldier and this is with the pulled out his his locker. Just a is one supplement. God knows what the compensation is in this group. Prevention, what do we do . We want to make sure that if you go to a site, but the acclimatization is hydration, we need to keep kids cool. Accountability, and there is accountability to the commanders to adhere to this table you see here. This is a work rust water consumption table. Classified we then calculate appropriate cycles and how much water should be divided good if you start to get heat strokes, commander will be held accountable, did you follow the guidance to keep people safe. A hydrationoduced guideline and i was part of this document. There are important point coming out of this document was to avoid problems. Drink when thirsty, for lead athletes they may need more and drinking at first may not keep them to their edge. Individual inflation. Has one strategy for everybody. That will not work because people are different. Also published a guideline and the High School Level the leverage of acclimatization so we can change the trajectory of premature death. By ognizes the phone or vulnerable transition. No uniforms. Threece should not exceed hours. Very detailed. They are trying to propagate this throughout all states to ensure safety of Football Players. Its also clear outside of the , i want to bring your attention to the climate is Time Strategy is it takes and it is not two days. We really have to be careful with this transition. We have to keep people cool because we have to keep people in the fight. Prevent heat, simple things here you see a vacuum cool device for his hand, the military is looking at the microclimate cooling devices to keep people cool down to their underwear and simple things like to precool so they can go forward and exercise. Very important. Andtimes we need to jump in say not going to be a good day. This is from the chicago marathon in 1996 race over three hours and there were some in the heat strokes and ran out of water that they had to stop the race. To years ago the race had stop as well, 30 heat strokes. Says thereaper that is a way to determine that do not start temperature that maybe we live tos to fight another day. Follow the data and start to develop a plan that says maybe we go tomorrow, keeping you in the fight for a future marathon. Second intervention, i was moved , this isealys word what we leverage in the military, the buddy system, where somebody says johnny does not look right and they bring him to a medic. Cases whensentinel you see things pop up with one particular team or unit while having a bad trend something is not right. The other thing we do is we leverage the concept of what we call sheets heat dumping. Leveraging a hand cooling device. In the military we leveraged showers, we run kids through these all the time, the other thing is we have these cooling systems that are just towels filled with cold water, the kids do this to keep themselves school throughout. Prevention means gear ready. When somebody drops Everybody Knows the plan. Down in fort benning we have barrelsilled with filled with ice. This intervention alone will help to say that young mans life. The other thing and address should to this drill sergeant is we need rapid cooling intervention being prepared. We use a different technique where we have a gurney here forended over ice water cold water immersion. This is a picture from the marine corps marathon. With that being said it is a sheet attack. Heat attack. We have a detailed emergency races,plan for all the they had 100 heat strokes last summer. Away becauseks there is a good plan and they execute it and they practice it. Treatment here is immersion preparinghen we are to treat with reparations for transfer. It is all about a plan, practicing the plan and executing the plan. Exercised, this was an class associated with sickle cell trait. Generally thought to be a benign condition but it is clear in the sickleure will, that cell trait is associated with sudden death and other complications as you see here. If youry client are africanamerican you have 30 times the risk of sudden death in that first year if you have sickle cell trait. Has also established that africanamerican sickle cell politician , Football Player you sudden absolute risk of death. Deaths ande of these some of these sickle cell trait fall into another category. Lightning strikes that are common use that analogy. Are rare socations we need to have the right talents and the right near it up when we communicate to africanamerican athletes what is their risk and what is not their risk. What do we know about these deaths . These are drawn from case come up one athlete died in a workout. The unconditioned military recruits in that transition. , limited timeed for recovery and on cardiac arrest the athlete goes down, i cant with my legs, i cannot walk and there initially alert. This is a detailed slide taking a look at how the sickle cell trait cause death . There is a local environment here, increased temperature that somehow we are precipitant precipitating a crisis. There are a lot of different thoughts. Heat is thelieves principal culprit. Some think its all about hydration. A Team Physician oklahoma, keith is no more a trait for sickle cell trait. He believes that intensity is the key variable. This. Very interested in trill if you are sickle your ratecell trait of death is one and 1000. Same as had the why they dont doubt. That is interesting to us. What we are trying to uncover and explore is that maybe all sickle cell trait athletes are not the same. There might be Something Different in some that predisposes them. Of prevention the doctor talked about the screen 1, 2, and three that is recommended. You can wave out if you want but screen in is mandating mandated. ,he level for physicians is there are some people that said we oppose the screen. You are screening for genetic variations, this has the potential to harm potential athletes and may create a false narrative. This is a tough issue when you are dealing outside of the ncaa or athletes in the military on what to do. Commonsense guidance i give to parents of high schoolers, in journal of student athletes we ,ee here some of the key things preseason conditioning programming. A performance tests such as a serials brent sprint if it is not a normal activity for you will stay hydrated and refrain from exercising few are ill and seek ethical care. It speaks to universal commonsense guidelines and a clear recognition of transition. And they prevention doctors new document emphasizes these points. Recognize in athlete who is struggling. As we heard from mrs. Shealy this morning and when they are down to help them up. Most importantly. And finally develop an adequate Emergency Action plan that is practice and ready to go. , theso includes hydration single most important thing and africanamerican athlete can do is to stay hydrated. , we give aevention brief to everyone who comes in so they are aware of their risk and we have an 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 quickly. Tos is just an education best tool i will show you. We have different videotapes we produced in a department of defense to give you to trace people, to the doctors and to the soldiers. But we areabor this trying to use these tools to get them to the right people. Bottom line, try to be prepared. A Football Player at west point, first day, he had just graduated. This is an issue for us in the military, we track this and are hypernatremia deaths have been heightening. It has been a real problem. One person died in the Boston Marathon that became an issue. Temperaturenormal but there are changes. This is a person working at an change. Eds to be a what we know from the literature , a couple of things. 3 1 ofhat common entrance those people with longer finishing times, 10 to have a greater risk and most when theye is are down and vomiting the answer is string more get up and run. Only, shed died in the medical tent that day at ,he marine corps marathon, 36 hyponatremia and she was vomiting and was given more water. Water impact has been dialed down. We actually give less water to try to avoid hypernatremia. Increasing water stops to greater distances to avoid this complication. Is todration guidelines have to know yourself and recognize that people are different and will create different stresses. Secondary prevention you see now in races, this is from the should notman, you gain weight when you are exercising. If you are gaining weight that is a tip off that it might be a hyper no hyponatremia. Doug brenner, this is biggs is this is we are seeing an between 2013mber and 2016 our numbers one of 50 . This may be the training or it may be the pool of fitness of individuals coming in the military but this affects our ability to train and be ready. Its not just the military. This was published by a colleague of mine, offseason describediowa players militarypracticing, cohorts say we looked at 40 cadets in brockport who were run hundredmile , all these00 squats kids have done it before with the problem but then someone decided to put a clock to it and put 40 of the kids in the hospital when you put a clock up. Exertional and providers need to be alert a can be the flu, it can be ecstasy or cocaine, number of things can contribute to this. As a position you need to have your thinking caps on to its usually when a perfect storm. Omes together who is coming in, whats the transition time, whats the intensity. Many nonexercise illness, not sleeping drugs,ickle cell trait, statins, supplements. I would strongly agree where i think what mr. Shealy was trying to point out the most important variable looking at these cohorts, leadership. Heatstroke, these kids will do what you ask. It is leadership. Take this slide wherever i can. I think this is a very powerful guidance that the doctor put out in 2019 identifying the vulnerability, transition. And Holding People accountable. Ratio of 14. St workout should be documented in writing, you want to have the best of the best to our writing these programs. I saw a very powerful statement and we push it. Prevention secondary it is no joke when you are in the hospital for 39 days fighting for your kidneys or ending up in dialysis. Prevention we published guidelines on this at this point in time. Walks providers all the way through on how to manage this entity so we can get troops back to duty. I want to conclude again and honor for me to be here to speak on behalf of derek shealy. I think this is largely preventable. Commonsense recommendations as we heard from dr. Hamline, and emergencyas we say in the militd again, i truly believe leadership remains the key risk factor for the injuries i have described and it is the most important variable for improvement. Thank you. [applause] thank you dr. Oconnor. It is now my pleasure to introduce dr. Cardenas, the director of the concussion and brain injury center, the chair of the intercolette intercept interscholastic Advisory Committee. He is a leader in terms of helping advance all of the neurologists under the heading of concussion and traumatic brain injury. Just a little side note that you may not be aware of, it was not that three years ago concussion training became a mandatory part of a neurology residency training. It was always assumed that neurologists where the most knowledgeable in concussions. When i was trained, i had no formal training in concussions. It is now part of residency he is also and independent physician for the National Football league, and that has been an interesting and good experience where he believes that there has been Real Transparency on the field. Dr. Cardenas will talk about traumatic injury in sport, thank you for coming here. Dr. Cardenas thank you very much. I am honored to be here and present on this topic to the sheelys as well. I am greatly happy to do this. I will also disclose that i will be talking about traumatic brain injury, which derek died from. It is if these, whether the slides or stories from some of my own patients, become upsetting, i apologize in advance. I understand if you have to step away. A bit of those disclosures as in heard, my involvement this particular area spans all ages from youth to the itfessionals, and in this allows me to get a good understanding at how things are different, and how there could be changes, and the change is not going to be directional. It will not always come top down. There are many things that can be shared in both directions. When we are looking at catastrophic sport injuries, there are a significant number. The majority occur in high school. Fatal, and 50 serious. We will go over definitions in a moment. Competition, but some in practice. Has the greatest representation of catastrophic sports industries, and this data is primarily from high school and 55 represented versus basketball and other sports. Thisntity that is tracking is the National Center for Catastrophic Sports Injury Research center in north carolina, chapel hill. Its is a reporting system, is a voluntary system, but over the years they have been able to get more accurate data, because of social media, and they can reach out to different people in order and organizations and ask for the data to be provided. 1982,as established in and i know that many times coaches get a bad rap when it comes to football of pushing people through it, which may be the case. Established byas coaches who were attempting to analyze how these catastrophic injuries were occurring. A few definitions that you will want to know. Fatality is selfevident. None fatality is permanent, but severe injuries. This may be neurological. Serious injury is may not be severe or may not have a permanent deficit. Someone who suffers a spine fracture but does not suffer a spinal cord injury. The mechanisms, direct f