Two Casualties at Once on a 41 °C Sports Day

Runner A is treated first, and the ankle waits. The decision rests on time-critical risk, not on who is crying louder. Confusion, hot dry skin, absence of sweating and a temperature above 40 °C point to heat stroke, not heat exhaustion; heat stroke is a medical emergency in which organ damage progresses with every minute of delay, and mortality is closely related to how quickly cooling begins.

Immediate actions for A

1. Move him to the classroom block shade and lie him down with legs slightly raised.
2. Call 108 and state 'heat stroke, confused, temperature 40.3' – do not wait to see if he improves before calling.
3. Remove excess clothing and start cooling at once: wet cloths or ice packs at the neck, armpits and groin, fanning, and sponging with water. Cooling must begin before and during transport, not after arrival.
4. Do not give fluids by mouth – he is confused and his airway is at risk.
5. Check breathing and keep monitoring; send a second person to arrange transport.

Why this order. The ankle injury will not worsen dangerously in fifteen minutes. Heat stroke will. The one trained teacher should stay with A and delegate the ankle to another adult using the box – splitting attention between two casualties is how the critical one is lost.

Immediate management of B

• Rest: she is carried or helped off the pit; no further jumping or walking tests.
• Ice: ice pack wrapped in cloth for 15–20 minutes, repeated every two hours. Never place ice directly on skin.
• Compression: crepe bandage applied from the toes upward, firm but not tight; check the toes for warmth, colour and capillary refill after bandaging, and loosen if they turn pale or cold.
• Elevation: ankle raised above the level of the heart.

What must not be done

• No heat, no balm, no massage, no 'run it off' – all increase bleeding and swelling.
• No forced weight-bearing test to 'see if it is broken'.
• No painkiller handed out by an untrained adult, and no tightly bound bandage left unmonitored.

Referral decision. Swelling this rapidly is not automatically a fracture, but a fracture cannot be excluded by looking: the reliable clinical signs are bony tenderness at the malleoli and inability to take four steps. Since she can bear a little weight and there is no deformity, this may be a ligament injury – but the hospital is 22 km away and a missed fracture in a 14-year-old is far worse than an unnecessary X-ray. Send her with a responsible adult for examination and X-ray, with the ankle elevated and the bandage in place.

Neither athlete returns to competition today.

Runner A. Heat stroke is not an event you recover from within the afternoon. After cooling, he needs hospital assessment because of the risks of electrolyte disturbance, muscle breakdown and kidney injury. Return to training is a medical decision, graded over roughly one to two weeks in cool conditions, with a gradual reintroduction of kit and intensity. Sending him back on the same day in the same heat would risk a second, often worse, episode.

High jumper B. The temptation is to accept 'it feels a bit better' as clearance. That is not a criterion. Safe return requires: no swelling, full pain-free range of movement, pain-free hopping on the affected leg, and pain-free jogging, changing direction and jumping. That normally takes one to three weeks, not one hour. Deciding otherwise in the first hour is impossible because swelling peaks later and the initial adrenaline masks pain.

The judgement being tested. Return-to-play decisions must be based on objective criteria and on the risk of the worst outcome, not on the athlete's wish, the coach's need for a result, or how the joint looks at that moment. In both cases the correct answer is the same, but for different reasons – one for systemic danger, one for structural uncertainty.