











































MANUSCRIPT TYPE


DISABLEMENT MODEL CASE STUDY 

 

45 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 5 – Issue 2 – September 2022 
 

Exertional Heat Stroke in a Male High School Runner with Disordered 
Eating: A Disablement Model Case Study 
Brittni G. Hoover, MS, LAT, ATC*; Rebecca M. Hirschhorn, PhD, ATC, NRAEMT†; Allison B. Smith, PhD, LAT, ATC‡; Amy F. Hand, PhD, 
SCAT, ATC** 
*University of North Carolina at Charlotte, Charlotte, NC; †Louisiana State University, Baton Rouge, LA; ‡University of Louisiana at 
Lafayette, Lafayette, LA; ** University of South Carolina, Columbia, SC 

 
ABSTRACT 
A 16-year-old male high school cross country athlete collapsed at the end of an afternoon 5K cross country meet. The patient was 
unable to stand, and after outwardly displaying confusion and agitation, his coaches sought assistance from the athletic trainers 
(ATs). The patient consumed one cup of water and a granola bar on the day of the meet. The ambient air temperature was 90°F 
with 69% humidity. Differential diagnoses included exertional heat stroke (EHS), exertional heat exhaustion, exertional collapse 
associated with sickle cell trait, heat syncope, dehydration, malnutrition, and hypoglycemia. Approximately 20 minutes passed 
between activation of the emergency action plan (EAP), initial collapse, and cold-water immersion. Assessment of rectal temperature 
did not occur until after submersion due to waiting for parental consent. The patient was removed from the water after 12 minutes 
with a rectal temperature of 100.5°F. He was transported to the hospital, received 2 liters of intravenous normal saline among 
multiple other tests, with no significant findings, and was released approximately 9 hours later. It was later learned that the athlete 
dealt with disordered eating. The patient was asked to complete a seven-day food and drink log and was provided nutrition 
guidance by the ATs. This patient’s disordered eating habits could have contributed to the development of EHS. The ATs were 
unaware of his eating patterns until after the EHS event. Athletes need to be educated on how to properly fuel themselves for athletic 
competition in anticipation of adverse environmental conditions. If a patient is already prone to disordered eating, this individual 
will not have the proper intake of nutrients to sustain athletic competition, nor to sustain everyday living. Athletic trainers should be 
aware of all potential medical concerns in their patients, including those not often discussed, to accurately diagnose conditions and 
avoid any potential sequelae. 
 
 
Correspondence 
Brittni G. Hoover, 1300 Wheat Street, Columbia, SC 29208. 
E-mail: bghoover@email.sc.edu 
Twitter: @BrittHoover2 
 
Full Citation 
Hoover BG, Hirschhorn RM, Smith AB, Hand AF. Exertional heat stroke in a male high school runner with disordered eating: 
A disablement model case study. Clin Pract Athl Train. 2022;5(2): 45-51. https://doi.org/10.31622/2022/0005.02.8.       
 
Submitted: May 4, 2021 Accepted: July 26, 2021. 

 
INTRODUCTION 

Exertional heat stroke (EHS) is the most severe exertional heat illness (EHI) characterized by a core body 
temperature exceeding 105°F, the presence of central nervous system (CNS) dysfunction, and multiple organ 
system failure.1-5 When the metabolic heat produced by muscle during activity outpaces body heat transfer 
to the surroundings, the core temperature rises to levels that disrupt organ function, unless correctly 
recognized and treated in a timely manner.2,5 Care should begin within 30 minutes of initial collapse to 
include cooling from the neck down.6 Relevant to this case study, high school boys’ cross country has been 
found to have an EHI incidence rate at 0.52 per 10,000 athlete-exposures per cross country season, during 
competition, and 0.50 per 10,000 athlete-exposures in practice, the second-highest EHI rate following boys’ 
American football.8 Exertional heat stroke is one of the leading causes of sudden death during activity.1,2  

Risk factors for EHS include lack of heat acclimatization, cardiovascular dysfunction, fever, illness, 
dehydration, and hypokalemia, among others.2 Some of these factors can also be directly associated with 
eating disorders.5 Eating disorders can be determined by using questionnaires such as the Eating Disorder 
Examination (EDE). This questionnaire includes questions related to eating disorder (ED) risk. These questions 
are specific to sport and are related to being diagnosed.6 If an individual is not consuming enough nutrients, 
it can result in low energy availability, health risks, and ultimately affects bone mineral density.5 Disordered 

http://bghoover@email.sc.edu
https://doi.org/10.31622/2022/0005.02.8


Exertional Heat Stroke in a Male High School Runner with Disordered Eating: A Disablement Model Case Study 

46 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 5 – Issue 2 – September 2022 

 

eating behaviors are similar to eating disorders, but they do not meet the criteria for diagnosis.7 Relevant 
risk factors pertaining to this case include that the patient struggled with disordered eating (DE).7 If not 
addressed appropriately or in a timely manner, DE can result in physiological and psychological effects. 
Some of these include inadequate energy availability, decreased bone mineral density, and for females 
specifically, menstrual disorders and the female athlete triad.6 In athletes who completed the EDE-12 
questionnaire, body dissatisfaction, drive for thinness, and body mass index were found to contribute to their 
DE habits.8 In males specifically, body dissatisfaction has been found to be linked to muscularity and weight 
concerns.6 In this case, the patient’s family was previously aware of his nutritional habits; however, the ATs 
at his school were not.  

PATIENT INFORMATION 

The patient in this case study is a 16-year-old male high school cross country athlete that collapsed at the 
conclusion of an afternoon 5K cross country meet. At the time of the incident, the patient was in the 11th 
grade and had been participating on the cross-country team since middle school. There was no documented 
family history of heart disease, diabetes, ED, or mental health disorders. He had no previous history of ED, 
injury, or other illness. On the day of the meet, which started at 4 pm, the patient had only consumed one 
cup of water and one granola bar. At the time of the collapse, the ambient air temperature was 90°F with 
69% humidity, which is in the dangerous percentile and increases the risk of EHI.9 These measures were not 
determined until after the collapse occurred.  

Differential Diagnosis and Evaluation 

The differential diagnoses were EHS, exertional heat exhaustion, exertional collapse associated with sickle 
cell trait, heat syncope, dehydration, malnutrition, and hypoglycemia.2 When the patient first collapsed at 
the finish line, the ATs decided for the patient to drink water and sit down since he was conscious, alert, and 
oriented. Due to the patient’s fatigue, he was assisted to the team tent by his coaches and teammates. The 
patient’s presentation drastically changed after arrival at the team tent, which is when the coaches called 
the ATs for assistance. The most notable changes included signs of CNS dysfunction (confusion, inability to 
form speech, unaware of date, place, time, personality change/aggression), feeling of extreme overheating 
of the body that could not be cooled with water, and extreme fatigue (inability to walk or stand). The patient 
was transported from the team tent to the athletic training facility where cold water immersion and a rectal 
thermometer were available. At this time, emergency medical services were called. Since the patient was a 
minor, the AT’s policy was to get parental consent prior to the use of rectal thermometry and immediately 
initiated cold water immersion. The patient’s parents were not at the race and were called to receive 
permission to utilize the device. After the patient was immersed for 12 minutes and showed obvious signs of 
improved CNS function, the ATs removed him from the cold-water immersion tub and assessed his rectal 
temperature after receiving parental consent. At this time, his rectal temperature was 100.5°F, and it was 
determined that the patient was now able to be safely transported. Emergency medical services then 
transported him to the hospital, where he received further evaluation and care.  

Body Structure and Function 

The body function most affected was his CNS, as shown through his delirium. When talking to the patient 
after the event, he recalls that he felt an out-of-body experience. The patient expressed that he knew 
something was wrong, but he did not know what was going on. The best practice, or gold standard, of 
immediate treatment for EHS is the assessment of rectal temperature and cold-water immersion.1,3   



Exertional Heat Stroke in a Male High School Runner with Disordered Eating: A Disablement Model Case Study 

47 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 5 – Issue 2 – September 2022 

 

Activity and Participation 

At nine months since the event, there are no documented long-term negative effects on the patient’s health 
as a result of his EHS event. The incident made the ATs aware of the patient’s DE behaviors. Additionally, 
the patient expressed that it made him realize the drastic effects that his DE can have on his body, and he 
began to change his eating habits. This event shows clinicians that DE presents in males as well as females. 
He has worked with his parents to improve his DE. The patient took time off from running to help his body 
heal. It is important to note that DE is not an overnight fix and takes months and sometimes years to get to 
a healthy place.  

Environmental and Personal Factors 

The patient expressed that the nature of the sport of cross country and associated physical appearance 
standards, the overwhelming media push to “look skinny,” and the myth shared throughout his high school 
that you should not eat too much as an athlete, were all factors that led up to his DE. He shared that his 
teammates’ support had a huge hand in the difference between him having a successful and unsuccessful 
recovery. Parental involvement was a key factor in his recovery process, as well, due to their constant support 
without judgment. This patient, in particular, expressed that the encouragement that he received from his 
teammates and family is what helped him face his DE and get on a path to recovery and healing. 

INTERVENTIONS 

Due to the patient’s personality changes and aggressive behavior, indicative of CNS dysfunction, the ATs 
initiated the emergency action plan, which was to call emergency medical services and immerse the patient 
in cold water. The cold tub was not located at the cross-country course, and the patient had to be transported 
to the athletic training facility for cold-water immersion, resulting in approximately 20 minutes passing 
between initial collapse and cold-water immersion. The patient had partial consciousness and was unaware 
of the events happening during the cold-water immersion. After 12 minutes of cold-water immersion, the 
patient’s cognitive function improved, so he was removed from the water, and his rectal temperature was 
assessed. At that time, his core temperature (100.5°F) was determined to be safe for transportation by 
emergency medical services, who arrived shortly after his immersion. At the hospital, he received two liters 
of intravenous normal saline and was administered multiple tests, including an electrocardiogram and blood 
panel, with no significant findings. He was released approximately 9 hours after arriving at the emergency 
department following the resolution of symptoms.  

The patient followed up with his AT the following day, who had since been informed of possible DE by a 
concerned peer. The patient was asked to complete a 7-day food and drink log and was provided nutrition 
guidance where he logged everything he ate and drank each day. In the mornings, he reported to the 
athletic training facility prior to school to review what he ate prior to practice the night before and to report 
his breakfast intake prior to school for the day. He also reported to the athletic training facility at the end 
of each day, where the log was reviewed. If he did not consume adequate calories based on the 
recommended daily intake values, he was not permitted to practice.10,11 On the days that he was not in 
school, he contacted the head AT to report his documented intake electronically.  

OUTCOMES 

The only quantitative data, or validated outcome measures that were taken, were taken during the initial 
incidence. Based upon conversation, his body has returned to normal function, and he is now able to 



Exertional Heat Stroke in a Male High School Runner with Disordered Eating: A Disablement Model Case Study 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 5 – Issue 2 – September 2022 

 

participate in full activity. In addition to completing the 7-day food log and daily check-ins with the AT, the 
patient’s return to play included an evaluation of the nutrients that he took in every day and if that fulfilled 
his requirements to participate in sport. If he did not meet this threshold, he was not allowed to practice that 
day.  His running mileage was also greatly lowered. He began his return to play with biking and walking in 
the athletic training facility, to progressing to walking with a friend and a mile of light running. After 7 days, 
he had built up enough nutrient intake as well as mileage increase to return to full practice. Due to concerns 
over the patient running alone, it was decided to have a friend run with the patient during his return-to-play 
in case another situation occurred while they were out on the course. The patient has continued to address 
his DE behavior, but the family has kept the continued process personal.  

DISCUSSION 

Certain aspects of this case that are important to note, such as the delay in assessing rectal temperature to 
confirm an EHS diagnosis, wet-bulb globe temperature (WBGT), which had not been used prior to or during 
the event, and the lack of immediate on-site access to cold water immersion. Rectal thermometry is the gold 
standard of care to assess core body temperature during a heat illness event.9,11-14 Methods such as oral or 
temporal temperature assessment are inaccurate.15 However, recent literature still demonstrates that most 
secondary school ATs do not assess a rectal temperature during suspected cases of EHS.9,11-14 Less than half 
of surveyed ATs reported that they were comfortable using a rectal thermometer to assess for EHS.15 In this 
situation, the ATs wanted to protect themselves in case the parents did not give consent. However, rectal 
thermometry is the standard of care for athletic training for heat-related illness emergencies, as stated by 
the NATA,2 and therefore, it is the required practice of care, regardless of parental consent or the patient 
being a minor.1,2 Barriers to implementing the use of rectal thermometers have been found to be lack of 
training with equipment, misunderstandings of use and cost, and the possibility of legal issues.16 There are 
also extrinsic factors that negatively impact ATs use of rectal thermometry. For example, in some cases, 
school administrators may express concerns with the use of rectal thermometry on minors. This has especially 
been noted by ATs that work in private school settings.4 Recommendations to overcome these barriers include 
proper education of these devices explaining the importance of understanding the efficacy of the 
temperature measurement compared to other tools.17 Ultimately, it is the AT’s responsibility to ensure 
meetings with administrators are held prior to such events so that all individuals are on the same page when 
it comes to emergency action plans and protocols. In this case, the ATs had not gotten prior permission from 
the parents to utilize this standard of care. This should be explained to parents prior to sport participation, 
and a form signed that gives the ATs the right to care for their student-athletes using rectal temperature if 
the parents are not present at the time of the incident.2 There is a heat stroke treatment authorization form 
that is created by the NATA that clearly lists out the proper evidence and the definitions of the AT’s scope 
of practice that parents and guardians can sign at the beginning of every season.18 

The day of the patient’s EHS event was one of the hottest days within the first few weeks of the cross-country 
season. The team was only a few weeks into regulated practices and had not gone through a low to high 
increase in practice mileage/intensity or regulated acclimatization period during those weeks, nor did they 
have any regulated summer practices. This day, in particular, was too hot for participation in sports (90°F 
and 69% humidity) based on the ambient temperature and relative humidity.3 According to the heat stress 
risk temperature and humidity graph,19 if the relative humidity is between 50-60% ambient temperature 
should not exceed 86-90°F for safe sport participation.16 However, there were no modifications to the 
competition based on the extreme environmental conditions. Ideally, a WBGT device should have been 
utilized, and the event delayed or postponed until the conditions were more favorable; however, a WBGT 
reading was not utilized prior to that day’s events.3 WBGT is preferred to ambient temperature and radiant 



Exertional Heat Stroke in a Male High School Runner with Disordered Eating: A Disablement Model Case Study 

49 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 5 – Issue 2 – September 2022 

 

heat alone due to differences in weather effects within various regions of the country.2 WBGT is calculated 
by completing a mathematical equation including wet-bulb temperature, black-globe temperature, and dry-
bulb temperature.2 Lastly, the facilities where the cold tub was located, were a 5 to 8-minute walk from the 
finish line and team tents. Precious time was lost during the commute from the team’s tents to the place where 
the cold tub was utilized. Since the patient was being carried, this also added to the time that he could have 
been in the cold tub. Rectal thermometry and cold-water immersion were utilized within the 30-minute 
recommendation after the start of treatment, supported by the NATA position statement for standard of 
care for EHS.2,19 

CLINICAL BOTTOM LINE 

It is important for ATs to ensure they are up to date on the standard of care that is expected of the profession. 
Emergency action plans for situations like this should be implemented and practiced prior to an event 
occurring. ATs should be in contact with emergency personnel to make sure that the standard of care is 
continued during and after transportation to a hospital. EHS can be avoided if prevention and recognition 
are practiced correctly. Individuals presenting with EHS must be cared for within a short amount of time to 
prevent serious injury or death. It is the AT’s responsibility to ensure all important personnel are trained and 
ready for any emergencies that may occur.2 With the proper training, pre-participation examinations, and 
weather precautions in place, EHS can be avoided and potentially completely prevented. 

This case is important due to the rise of EHS in both the high school and college athlete populations.10 Rectal 
thermometry has been the gold standard of practice since 2002, yet many ATs still do not feel comfortable 
performing it if they did not learn this in their schooling.1,12 Since this information was published 18 years 
ago, this standard of care should be fully accepted and administered across the athletic training world. 
Athletic trainers are responsible for learning and implementing new athletic training competencies into their 
practice, even after obtaining their initial certification.20 State, regional, and national conferences should 
provide opportunities for ATs to learn and practice these skills to help facilitate implementation to practice.  

ATs should be aware of other factors that could affect and increase risk of EHS. In this scenario, disordered 
eating was a factor that led to the patient's EHS. Other factors of this EHS event included lack of supplies, 
AT preparation, and difficulty accessing emergency equipment. It is important for athletes to have a basic 
understanding of proper nutrition guidelines for their sport participation and how environmental conditions 
may further compound.8,21 Outdoor sport athletes need to be especially careful due to potential exposure 
to adverse environmental conditions.4 It is suspected that the patient’s DE had a key effect on his dehydration 
and lack of nutrients to be able to successfully compete in his race.  

The authors recommend three important take-a-ways from the experience. One of the most important things 
that an AT can do with their staff is to review and practice their EAPs, annually.2,4,5,16,19 This plan includes 
instructions on what to do in case of an emergency, and more specifically, a heat related illness event. Rectal 
thermometry should be available to all ATs at every level, even including secondary schools. 1,2,4,16,17 There 
are certain forms and parameters that can be navigated to gain permission from parents in regard to minors. 
ATs should consider screening athletes for nutritional concerns prior to sport participation through pre-
participation exams (PPEs) and throughout the season utilizing validated risk assessments, such as the EDE-Q 
and EDE-12 questionnaires.6,8 ATs should be aware of all potential medical concerns in their patients, 
identified through PPEs, to properly refer to physicians or specialists and diagnose conditions to avoid any 
potential sequelae. If ATs adopt the regular use of EAPs, rectal temperature, and PPEs in their practice, 



Exertional Heat Stroke in a Male High School Runner with Disordered Eating: A Disablement Model Case Study 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 5 – Issue 2 – September 2022 

 

incident rates of fatal heat related illnesses should drastically decrease due to the awareness gained through 
these three avenues. 

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All rights reserved. ISSN Online 2577-8188                                                                     Volume 5 – Issue 2 – September 2022 

 

18. Kerr ZY, Casa DJ, Marshall SW, Comstock RD. Epidemiology of exertional heat illness among U.S. high 
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https://doi.org/10.1080/10903127.2017.1392666

	ABSTRACT

