Collapse at the 400 Metre Race on Sports Day
On 12 April a school holds its annual sports day from 11 a.m. to 2 p.m. The temperature is 38°C and relative humidity 65%. There is one water tap for 900 students and no shade at the far end of the ground. Uniforms are dark blue. At 12:40 a 14-year-old boy collapses after the 400 m race. He is confused, answers slowly and cannot stand. His skin is hot and dry, pulse 132 per minute, breathing 26 per minute, blood pressure 100/60 mmHg, temperature 40.1°C. He has not passed urine since morning. Two boys who ran earlier sit under a tree with painful leg cramps and nausea, but are alert and sweating. The physical education teacher wants to pour cold water on the collapsed boy, give him a salt-and-lemon drink, and send him home in a rickshaw. Another teacher objects that cold water will cause pneumonia.
1. Classify the two presentations and explain the physiology that separates them.
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These are two different conditions.
The two boys with cramps are alert and sweating, with normal temperature - heat exhaustion with salt loss. Sweating continues, so cooling still works; the problem is water and electrolyte depletion. Shade and oral fluids are enough.
The collapsed boy has exertional heat stroke until proved otherwise:
- 40.1°C with hot dry skin - sweating has stopped, the last defence has failed
- confusion and inability to stand - central nervous system dysfunction, the defining feature that separates heat stroke from exhaustion
- pulse 132, respiration 26, BP 100/60 - cardiovascular strain as vasodilation and fluid loss cut effective circulating volume
- no urine since morning - dehydration was already present before the race
Physiology: heat from working muscle exceeds what radiation, convection and evaporation can remove. At 65% humidity evaporation is already inefficient; dark uniforms and open ground add heat load. Once sweating fails, core temperature rises unchecked, proteins denature, and brain, kidney and clotting are at risk. The decisive difference between the two presentations is confusion, not temperature alone.
2. Judge each of the teacher's three proposed actions and give the correct immediate sequence.
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Cold water - yes, this is the treatment. Immersion or repeated dousing is the fastest way to lower core temperature. The pneumonia objection is wrong and dangerous. Cool first and argue later; the aim is below 39°C within about 30 minutes.
Salt-and-lemon drink - no. He is confused, so oral fluids risk choking and aspiration; he needs intravenous fluid. The drink is appropriate for the two boys with cramps, who are alert and can swallow.
Home in a rickshaw - absolutely not. Transport must be by ambulance with cooling continued on the way; a closed rickshaw in 38°C heat will raise his temperature again.
Correct sequence: call the ambulance → move to shade → remove excess clothing → douse or immerse in cold water with fanning → check airway and monitor → nothing by mouth → hospital.
Do not give paracetamol or aspirin. They lower a raised hypothalamic set point, which is not the problem here, and can add liver or bleeding risk.
3. Redesign the sports day for next year and justify each change physiologically.
Read the worked answer
Change the schedule and environment, not the students' willpower:
- Time: events before 9 a.m. or after 5 p.m.; scrap the 11–2 window entirely.
- Water: at least four taps plus volunteers carrying bottles to the far end; announced drinking breaks every 20 minutes.
- Shade: canopies or tents at the far end, and a rest area with fans.
- Clothing: light-coloured cotton house colours for the day instead of dark blue, which absorbs radiant heat.
- Acclimatisation: two weeks of practice sessions; unacclimatised children are at highest risk because they sweat less and at a higher salt cost.
- Pre-race screening: recent fever, diarrhoea, no urine since morning, or current medication means sitting out.
- Trained staff and equipment: one teacher per 100 students trained in cooling and first aid; ORS, stretcher and standby ambulance at the ground.
- Heat rule: shorten or cancel events when a set combination of temperature and humidity is crossed.
Justification: each measure attacks one route of heat gain or loss - production, evaporation, radiation and convection, or hydration - and none relies on a child reporting thirst, which is an unreliable signal in heat.