Collapse at the 800 m final: heat exhaustion or heat stroke?
It is the inter-house sports meet at a school in Anuradhapura in early April. The track surface is measured at 41 °C and the humidity is high. At 1.40 p.m., during the 800 m final, a 15-year-old boy in the second lane slows down, then stumbles and collapses near the finish line. His teammates want to sit him under a tree and give him a bottle of cold water to drink. When you reach him he is breathing fast, his skin is hot and dry to touch, his face is flushed, he answers your questions but is confused about where he is and cannot say what day it is, and he has stopped sweating. Two teachers are nearby; one says he is probably just dehydrated from not drinking enough and suggests he walk to the shade. The school has a first-aid room 300 m away, a tap, ice in the canteen, and one teacher has a mobile phone.
1. Decide whether this is heat exhaustion or heat stroke. Justify your decision with the specific signs given, and explain why the teachers' plan - walk to the shade and drink water - is unsafe here.
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This must be treated as heat stroke, not heat exhaustion.
- Confusion about place and day is altered mental state. That single finding is what separates heat stroke from heat exhaustion.
- Hot, dry skin with sweating stopped means thermoregulation has failed; the body is no longer losing heat by evaporation.
- Collapse during exertion in high heat and humidity, fast breathing, flushed face fit a core temperature above 40 °C.
In heat exhaustion the student sweats heavily, feels faint, dizzy or cramping, but is alert and orientated. Once orientation goes, the risk is seizure, organ damage and death.
The teachers' plan fails on three counts:
- Walking is effort. Muscle work makes more heat, which is exactly what a body that cannot shed heat does not need. He may collapse again and injure his head.
- Drinking is unsafe in a confused person. Swallowing may be unreliable, and fluid does not fix the problem - cooling does.
- Delay. The longer cooling is postponed, the greater the chance of lasting damage. "Wait and see" is the wrong default here.
So: treat as heat stroke, cool immediately, evacuate.
2. Set out your actions for the first 10 minutes and say who does what and why.
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Assign roles first, because speed matters more than tidy sequence. One teacher phones for an ambulance (in Sri Lanka the free 1990 service) and stays on the line; a second brings ice, towels and a bucket of water from the tap; a third moves spectators back.
Then, in order:
- Move him into shade and lay him flat. Twenty metres to shade is worth it; 300 m to the first-aid room is not, because cooling must not wait for transport.
- Remove excess clothing and shoes. Keep the shorts; the aim is skin exposed to air and water.
- Cool aggressively. Soak him, fan him, and put ice or cold wet cloths at the neck, armpits and groin, where large vessels lie close to the skin. Re-wet cloths as they warm - a warm towel cools nothing.
- No fluids by mouth while he is confused. Never force a drink; aspiration is a real risk.
- Check breathing and response every few minutes. If he becomes unresponsive but is breathing, put him in the recovery position and keep cooling.
- Do not give paracetamol or aspirin. They act on the fever set-point, not on a body that has failed to lose heat, and aspirin can add bleeding risk.
- Hand over times to the ambulance crew: when he collapsed, when cooling started, what was done.
3. What should the school change before next year's meet? Give three concrete changes and the reason for each.
Read the worked answer
Cooling is treatment; the timetable is prevention. The risk is predictable from heat, humidity and effort, so reduce exposure before anyone needs first aid.
- Timing. Move the 800 m, 1500 m and other endurance finals to before 10 a.m. or after 3.30 p.m., and keep field events in shade. Reason: the 1.40 p.m. slot combines peak heat with maximum effort.
- Water and shade points. A shaded rest area and refill point at the finish and at the 200 m mark, with a named teacher enforcing drink breaks. Reason: students often do not drink until thirsty, which is already late.
- Acclimatisation. Two weeks of graduated practice in the heat before the meet rather than a week of rest followed by sudden effort. Reason: heat tolerance improves with repeated exposure.
- A written heat plan and screening. Check runners on the morning for fever or recent diarrhoea and withdraw them from distance events; station one trained first-aider at the finish with ice, water and a one-page protocol. Reason: a written rule prevents the argument you have just had, and the first ten minutes decide the outcome.