Under A Cajun Sun

Last Sunday, due to church in the morning, work in the evening, and grass long enough to hide large rodents, I mowed the lawn in the middle of the day.  I was ready- I did each part of the yard when shaded by trees, wore my sun helmet (a wide, airy hat like mail carriers wear), and took frequent cooling and hydrating breaks indoors.  Going in for one of those breaks, I took off my helmet, and yelped when I burned my hand on it’s top.  It was HOT!

Heat injuries in children are increasing.  As the planet warms, there’s lots more opportunities for kids and teens to get dangerously overheated.  Also, kids are getting more obese, and bigger bodies generate more heat and shed it less efficiently.  And while the invention of car seats has saved kids’ lives in car accidents, they also make kids less noticeable and more easily forgotten, to be left trapped in hot cars.

What happens when you’re in the heat?  First, you sweat, and water evaporating off your skin takes heat with it.  You also turn red as blood brings heat to your skin surface, to radiate it away.  However, these mechanisms don’t work so well on hot humid days.  If it’s too humid, sweat won’t evaporate, but just accumulate on your skin, keeping your heat with it.  And if it’s as hot out as it is inside your body, there’s nowhere for the excess heat to radiate out to.  Finally, it takes time to “acclimate” to heat, where your body learns to sweat and radiate more efficiently; the typical teenager needs 10-14 days of outdoor work to get used to it.

If you cannot shed heat well enough, your core temperature begins to rise, and organs begin to cook.  “Heat exhaustion” is when early signs of heat injury arise.  As your brain heats, you get headaches, become easily confused, and have nausea and vomiting.  You get dizzy and fatigued from dehydration.  Muscles begin to cramp.  Then comes “heat stroke,” where the victim begins to stagger when walking, is delirious, may have seizures, before lapsing into a coma.

I experienced heat exhaustion myself once on vacation. While in North Carolina, I went running with my marathon-competing brother Pat.  I was fit enough to keep up, but didn’t consider that I always exercise indoors.  I wasn’t acclimated to heat like Pat, who trains outdoors. Half way through, my bald head (say it isn’t so!) began to cook in the sun.  I started having a headache, worsening fatigue, muscle pain, and nausea.  We cut home and I spent several hours in the a/c pouring cold water on my head, walking around to evaporate sweat, and slugging down gallons of fluids.

As we mentioned above, two groups of kids get heat injury: exercising teens, and small kids in hot cars.  If children or adolescents show signs of heat exhaustion like I did, it’s time to treat.  Get the child out of the heat: indoors to a/c, or at least into shade.  Strip off hot clothes and equipment (i.e. football pads and helmets).  Cool skin with cold wet towels, or ice baths with a cold towel over the head.  Hydrate with cold fluids.  If kids show signs of heat stroke- staggering, confusion, vomiting- get them to the ER.

To prevent heat exhaustion in athletes, they need to acclimate.  This takes 10-14 days, and should be gradual and safe.  Work-outs should be early morning or late evening when it’s coolest.  Avoid hot equipment like in football, lacrosse, and baseball catching, for the first weeks of practice: shorts and t-shirts only, helmets and pads later.  Players need frequent hydration breaks in the shade, with coaches vigilant for signs of injury.

Car seats have saved thousands of lives.  However, now that kids aren’t sitting in laps, they’re easily forgotten.  Children are often quiet in car seats.  Then when arriving at the store or work, you forget to take them out.  It doesn’t take very long, or even a very hot day, for a trapped infant or toddler to die.  Even on mild spring days, the sun can heat car interiors dangerously, even with cracked windows.  So never leave kids in cars, no matter how quick you think you’ll be.  Set alarms or other reminders when buckling your child in, to remember to take them out after the drive.

Stay Outdoors This Summer!

My college required students to take four blocks of Physical Education, much like high school, except we chose the sports.  We also had to pass a swim test to graduate.  My roommate Brian, who’d never learned to swim, had to use his PE blocks to take swim lessons until he passed that test.  So while the rest of my buddies and me were horsing around in floor hockey or golf lessons, Brian was off to the campus pool in swim trunks, towel around his neck, trailed by jokes about playing in the “kiddie pool,” and “don’t forget your water wings.”

Learning to swim and playing in the pool are great ways to spend the hot summer. It’s good exercise and though kids are outdoors, they stay cool.  And they have fun!  More importantly for we in Emergency services, knowing how to swim is good drowning prevention.

Proper swim lessons, like in the Boy Scouts, don’t only teach swimming.  They also teach water safety, because even good swimmers can get into trouble, like my buddy Walt. Walt is an ER doctor who had been in the Air Force Pararescue, or “PJs.” This elite team’s mission is to rescue downed pilots, particularly in water. Needless to say, Walt was as capable in water as any Navy Seal.  One day at the beach, however, he and his 8 year-old son got caught in a riptide and were taken out to sea.

Hundreds of yards off shore, Walt saw a current that would sweep them back, but the stream he was in prevented him from swimming there.  After hours of trying to break through while holding up his son, growing exhausted, he resigned himself to throwing his son to the beach-bound current before he himself drowned.  Just then a rogue wave slapped them into that good current and they got home.

After that, Walt never went to the beach without numerous flotation devices and a long rope.  Good swim lessons likewise teach about safety and rescue strategies like having flotation and other equipment handy.  They also teach the buddy system so everyone is accounted for in a crowd.

Playing outdoors in the summer is great exercise too, though not as cooling as swimming.  Kids can get overheated, especially if they are in sports practices.  Several times in July and August we get football players in the Emergency Department with heat exhaustion.  The boys start to get muscle cramps, and then can become sleepy and sometimes confused.  When they are confused or difficult to arouse, we worry about heat stroke, a life-threatening emergency.

Dr. James Andrews, a famed sports orthopedic surgeon, wrote a book called “Any Given Monday: Sports Injuries and How to Prevent Them.”  In that book he advocates kids cutting back on organized sports when they are young, to avoid repetitive injuries that he used to see only in college and professional athletes.  This allows for more unstructured outdoor play for kids that’s easier on their joints.  Kid-driven play also helps avoid heat injury.

In regular play, there’s no training agenda to drive kids past their comfort zone.  Kids can goof around outside all they want, and when they get hot and thirsty come in to get drinks and cool off.  They take breaks whenever they want.  In coach-driven sports, kids are pushed to the limits of their endurance to improve performance.  Sometimes they are pushed too far, and get over-heated.

However, organized sports practice can be made safer. Coaches should allow unlimited water breaks.  Heat injury happens with temperature and dehydration working together to punish; plenty of fluids prevents that.  Breaks should be in the shade.  Teams should practice in cooler times of day, early morning and late afternoon or evening.  Football practice should start with shorts and tee-shirts, with endurance and equipment gradually added in following weeks.  Finally, coaches should watch players for signs of heat exhaustion, just like they watch for signs of concussion.  If players acts groggy, they should be rested and hydrated in the shade.

So let your kids play freely outdoors. They should get swimming lessons and have lots of pool time to play and exercise.  If they are outdoors in the yard, be sure they take plenty of water and cooling-off breaks, and have sprinklers to play in.  Come to think of it, maybe football practices should have lots of running through the sprinklers too!

Heat And Light

If you think pediatricians don’t make mistakes raising their own kids, think again!.  My wife and I had just had our first baby.  When our girl was 6 weeks old, my wife was getting cabin fever, stuck home breast feeding around the clock.  We lived in eastern Maryland then, and decided to take a weekend at the beach for some fresh air and sunshine.  Being a pediatrician and a pediatric nurse, we were careful about the sun- big hat, sun tent, plenty of fluids.

We didn’t put sunscreen on baby and unfortunately, didn’t count on sunlight reflected off the sand and off the water.  Baby was lit up from below where her hat and tent didn’t protect and when we brought her home, she was the color of a cooked lobster.  Some experts!

Now it’s summer and kids should be outdoors swimming and playing, having fun and using their brains in healthier ways than with a phone, computer, or TV.  However, kids need protection from too much heat and light from the summer sun.  The most dangerous problem is children and teens overheating.

The heat-related tragedies are already making the news.  The story typically goes like this: the parent is in a rush, goes into a store and leaves the child in the car.  The parent is detained somehow and by the time he/she gets back to the car, the child is dead.  They always say, “I was only going in for a few minutes,” but unfortunately anything longer than a few minutes is all it takes.

Consider this: How long could you sit in a parked car in the sun, engine and A/C off?  Five minutes?  Ten, if you’re strong?  It takes about 40 minutes to bake a cake, about 20 minutes to bake a cupcake.  Now if you’re the cake and can only stand five minutes in the car before you are drenched with sweat and gasping and overheated, how long do you think your cupcake toddler can last?  The lesson is clear: don’t leave kids in a car in the summer at all, for any length of time!

Fortunately, these episodes of kids dying in hot cars is rare.  Much more common is heat injury with older kids during summer sports practice.  August is coming and with it, football practice.  I can count on seeing some kids in the Emergency Department with heat cramps, heat exhaustion or worse, heat stroke.

Heat cramps are the mildest of the sports heat injuries, where the kid athlete is working out hard, not stretching enough, not drinking enough, and not resting enough between bursts of activity.  He begins to get painful muscle cramps, and this means it’s time to stop, recover, stretch, and hydrate.

The next level of injury is heat exhaustion.  In addition to cramps, these kids begin to have dizziness, headache, and weakness from dehydration and over-heating.  If the child-athlete doesn’t take a break at this point, the next, worst, stage is heat stroke: the child becomes confused, lethargic, may stop sweating, and then is at risk for muscle and kidney and brain injury, and death.

To prevent heat injury, coaches and team captains should take these precautions: First, athletes need to adapt to the heat.  Start with work-outs of lighter intensity and shorter duration.  Football players should spend the first weeks of summer practice in shorts and t-shirts only; then progressively add intensity, duration, and equipment.

The second strategy is adequate hydration and recovery.  Athletes should drink before, during, and after practices.  There should never be limits on access to drink; coaches who restrict fluids are only hurting their kids, hurting their kids’ performance, and should be fired.

Finally, direct sun exposure should be minimized.  Teams should have a shady spot to rehydrate between work-outs.  Practices should be scheduled for earlier morning, like for 7am to 10 am instead of 8 to 11.  Afternoon practice should start at 4 or 6 pm instead of 2 pm.

Finally, coaches should have an action plan to handle heat injury.  Like surveillance for concussions, coaches should be watching players for signs of cramping, sleepiness, and headaches.

We all make mistakes, like when my wife and I accidentally sunburned our new baby at the beach.  Just please don’t make bigger mistakes by not taking heat seriously.


Boy, Is It Hot Out There!

When I was in high school, summers meant lots of exercise in the heat.  I would go for runs with sweat literally pouring off my arms.  Then came summer soccer practice- push ups and calisthenics, sprints and indian runs with grass clippings stuck to my arms and legs, coaches and captains yelling like army drill sergeants.  A lot of kids quit the team during the first weeks of practice.  Then I was glad for all the running I had done; it was a little comfort that I was maybe suffering less than the kids around me.

It is the time of year now when we all start hearing about the heat on the news.  The biggest and saddest stories are the ones about someone leaving their small child strapped in their car seat in the car.  They always say, “I was only going in the store for a few minutes.”  Unfortunately, a few minutes is all it takes to cause injury or death in an infant or toddler because of heat.  

How long could you stand it in a parked car, engine and A/C off, in the sun?  Five minutes?  Ten minutes?  Now compare people to baking cakes in the oven.  It takes about 40 minutes to bake a cake.  It takes 20 minutes to bake a cupcake.  So imagine you are the cake and your toddler is the cupcake.  Now how long do you think they will last in that parked car?  Again, even a few minutes is too much.

Fortunately, those infant and toddler tragedies are rare.  In the Emergency Department we see more cases of teenagers with heat injury.  These are usually kids on the practice field for school sports.  The mildest injury is heat cramps, where the only symptom is painful muscle cramps.  The next degree is heat exhaustion, where the teen has dizziness and weakness and headache from heat exposure and dehydration.  The most severe form of heat injury is heat stroke.  Teens with heat stroke become confused or unconscious, stop sweating, and are at risk for death.

Heat injury is preventable.  The first strategy is adaptation.  Athletes should slowly build to the harder work-outs, like I used to with my runs.  Start with work-outs of lighter intensity and shorter duration.  Football players should spend the first weeks of practice in shorts and t-shirts only.  Then progressively add intensity, duration, and equipment. 

The second strategy is plenty of hydration.  Athletes should drink before, during, and after work-outs, all three!  There should be no limits to access water or sports drinks.  Coaches who restrict fluids are only hurting their kids, and hurting their performance, and should be fired. 

Thirdly, school team work-outs should be scheduled for the early morning and late evening- start practice at 7am instead of 9am, or 6pm instead of 4pm.  There should be at least two hours between sessions. 

Finally, coaches should have an action plan to deal with heat injury.  Like surveillance for concussions, coaches should be watching their players for signs of cramping, sleepiness, headaches, weakness. 

Summer should be a fun time for kids outdoors.  But it’s hot out there, so treat your kids right in the heat.