Collapse at the Inter-School Cross-Country

Diagnosis: exertional heat stroke. The discriminators are central nervous system dysfunction (confusion, disorientation, ataxia) together with core temperature above 40 °C in a person who has been exercising in heat. Heat exhaustion, by contrast, gives weakness, dizziness, headache, heavy sweating and nausea with a core temperature usually below 40 °C and, critically, an intact sensorium. The vomiting and the low blood pressure support significant heat illness. "Dry skin" is not a reliable sign - do not use it to rule heat stroke in or out.

Actions, in order:

1. ABC and responsiveness. Check airway, breathing, circulation; place him on his side if vomiting; remove excess clothing and move him out of the sun.
2. Call the ambulance immediately - this is a time-critical emergency, and cooling begins while the call is made. Do not wait to see whether he improves.
3. Cool first, transport second. Cold-water immersion is the fastest method; if a tub is not available, apply ice packs to the neck, axillae and groin, pour cool water over him, fan continuously, and keep the skin wet. The target is to bring core temperature below about 39 °C as fast as possible; the duration spent above 40 °C drives mortality and long-term organ damage.
4. Do not give oral fluids while he is confused or vomiting - aspiration risk - and do not give antipyretics; they do not work for environmental hyperthermia and may harm the liver.
5. Monitor breathing, pulse, responsiveness and temperature every few minutes; record everything and hand over to the ambulance crew.

Why the shade-and-ORS plan alone fails: oral fluid corrects dehydration but does nothing to the core temperature, and delay in cooling is the main determinant of outcome. The teacher with the ice is closer to right; the disagreement should be ended by the person in charge, not argued in front of the runners.

Non-negotiable:

• Start time and season. A 1:30 p.m. start in the third week of May is the single largest preventable factor. Move to early morning (around 7 a.m.) and, if possible, out of the hottest weeks.
• Water stations every 1.5–2 km, not one at 2.5 km, with cups poured and ready, plus a finish-line supply.
• Medical cover: a trained first-aider or nurse on site, an ambulance or a vehicle on standby with a driver, a stretcher, ice, a cooling tub or large containers, and a shaded medical tent. A written emergency plan with a named person in charge and a rehearsed route for the ambulance.
• Heat policy: measure conditions (WBGT or at minimum temperature plus humidity) on the morning and at the start; publish a threshold at which the race is shortened, delayed or cancelled. Announce it in advance so there is no argument on the day.

Strongly recommended:

• Acclimatisation: 10–14 days of gradual exposure for runners who will race in heat; do not let a runner's first hot-weather effort be race day.
• Pre-participation screening for recent illness, fever in the past week, and any history of heat illness; a runner with diarrhoea or fever should be withdrawn.
• Runner education on hydration, warning signs (dizziness, confusion, stopping sweating, nausea) and the instruction that it is acceptable to walk or stop.
• Fewer runners per wave, staggered starts, and more shade and seating at the finish.

After the event: complete an incident report, review it with all staff, and change the plan in writing before the next meet.

Three days before: normal mixed meals with adequate carbohydrate at each meal (rice, roti, potato, fruit), and extra fluids so that urine is pale straw, not clear and not dark. Nothing exotic or unfamiliar. No salt tablets.

The morning of the race (about 3 hours before): a familiar carbohydrate-based meal, low in fat and fibre, plus 400–600 mL of fluid. About 30–60 minutes before: another 200–300 mL. The aim is to start euhydrated, not to "tank up" in the last ten minutes.

During a 5 km race in under-16 boys: the event usually lasts 18–25 minutes, so carbohydrate during the run is unnecessary. Water at the stations, a few hundred millilitres, is enough for most; a sodium-containing drink helps if sweat losses are large or the athlete is a salty sweater.

After: replace roughly 1.25–1.5 L of fluid for every kilogram of body mass lost, with sodium included, plus a carbohydrate and protein snack within an hour.

What to correct in the staff's advice:

• "Drink as much as you can" is dangerous. Excess plain water beyond sweat losses dilutes plasma sodium and can cause exercise-associated hyponatraemia, which presents with confusion and can be fatal. Thirst plus a planned volume, not maximum intake, is the rule; roughly 400–800 mL per hour during exercise is a working range, adjusted to sweat rate.
• Salt tablets are unnecessary with a normal diet and can worsen gastric upset.
• "No water during the race, it causes stitches" is wrong; dehydration and heat strain are the greater risk.
• Estimating sweat rate (body mass before and after a training run, plus fluid drunk) gives each runner a personal figure rather than a slogan.