Collapse at the 800 m final: heat stroke on the finish line
At a district-level inter-school athletics meet in Nagpur in May, the 800 m final starts at 15:40 with the ambient temperature at 38 °C and relative humidity around 70 %. You are the venue's sports physiotherapist standing at the finish area. A 16-year-old boy finishes fourth, walks about 15 m, then stumbles and collapses. His team coach runs over and starts splashing water on his face while a teammate tries to make him drink from a bottle. On assessment the boy is confused, does not know where he is, and answers questions slowly. His skin is hot and dry, his pupils are equal, his pulse is 150 beats per minute and weak, and his breathing is rapid. A touch thermometer supplied by the school reads 39.8 °C in the mouth. There is no shaded medical tent; the nearest ambulance is parked 200 m away. The organisers want the boy carried to the ambulance immediately so the meet can continue.
1. State your immediate priorities and explain the reasoning behind each, including how you would handle the organisers' request to move him at once.
Read the worked answer
Recognition first. Confusion and collapse after exertion, hot dry skin and a temperature near 40 °C means exertional heat stroke (EHS) until proven otherwise, not heat exhaustion. Heat exhaustion patients are generally lucid with normal mental status; this boy is not. Sweating can still be present in EHS, so dry skin supports the diagnosis but is not required.
Cool first, transport second. Carrying him 200 m would delay cooling by several minutes and is the wrong order. Outcome in EHS depends on how quickly core temperature falls below 39 °C - the target is within about 30 minutes of collapse.
Sequence:
- Call the ambulance while cooling begins; assign that job to someone else rather than doing it yourself.
- Move him into shade, remove excess clothing.
- Cold-water immersion is the gold standard - a tub, or improvised with tarpaulin and ice. If unavailable, ice towels to the neck, axillae and groin plus continuous dousing and fanning.
- Protect the airway. Do not give oral fluids - he is confused and aspiration risk is high. Do not give antipyretics; they do not act on heat-stroke thermoregulation and add liver risk.
- Measure temperature if a rectal thermometer is available; oral readings run low and are unreliable here. Repeat every 5–10 minutes and stop aggressive cooling around 38.5 °C.
- If the ambulance cannot cool, cooling continues on the field until the medics arrive, with a handover of collapse time, temperature readings and cooling method.
2. The coach asks when the boy can race again. What decision do you give, on what conditions, and what must be documented before that decision?
Read the worked answer
Answer to the coach today: he does not return to training today, and no running for at least the next 7 days. EHS is a multi-organ insult - rhabdomyolysis, acute kidney injury, liver damage and clotting abnormalities can develop in the first 48–72 hours even when the athlete looks well afterwards.
Preconditions before any running:
- Physician assessment including renal function, electrolytes, creatine kinase and liver enzymes.
- Full return of normal mental status and no residual symptoms.
- Written clearance, not a verbal "he seems fine".
Graded return: week 1 rest and walking; week 2 light, cool-condition exercise of 20–30 minutes; then a 2–3 week progression while monitoring body mass before and after sessions (a loss above 2 % suggests inadequate replacement), urine colour and session RPE. Return to competition only once heat acclimatisation has been rebuilt.
Documentation: time of collapse, initial and serial temperatures, mental status, cooling method and start/stop times, response, fluids given, EMS handover, parental notification and consent for information sharing, and the physician's clearance.
Also act on the venue: move the remaining events earlier, add shade and iced-water stations, cap warm-ups, monitor the wet-bulb globe temperature and confirm every school has an emergency plan. One EHS case usually signals a systemic failure, not bad luck.