Report Outlines Mistakes in McNair Tragedy

University of Maryland offensive lineman Jordan McNair visibly struggled to complete an outdoor workout May 29. In fact, teammates had to physically help the 6-foot-4, 341-pound McNair cross the finish line during a series of 10 110-yard sprints in the 83-degree heat that afternoon.

Twenty-nine minutes passed between the time McNair first reported cramping and the time he was transported from the field to a training room for treatment. Another 33 minutes passed before a team athletic trainer called 911. By the time McNair was placed in an ambulance, more than 90 minutes had elapsed. He died June 13.

Later that month, Maryland contracted with Dr. Rod Walters, a nationally recognized expert in athletic training, to conduct an investigation into the university's athletic training protocols and how university staff could have better handled McNair's heatstroke symptoms. Walters' 74-page report, released Sept. 21, provides lessons for athletic trainers everywhere.
 

Multiple factors
The report defines exertional heatstroke as "a medical emergency and the most severe of exertional heat illness." It can present through a variety of symptoms, most notably rectal temperature greater than 104 degrees Fahrenheit and central nervous system dysfunction (irrational behavior, irritability, emotional instability, altered consciousness, coma, disorientation or dizziness). "Additional symptoms can include headache, confusion, nausea or vomiting, diarrhea, muscle cramps, loss of muscle function/balance, inability to walk, collapse, staggering or sluggish feeling, profuse sweating, decreasing performance or weakness, dehydration, dry mouth, thirst, rapid pulse, low blood pressure, and quick breathing," the report states.

The report goes on to emphasize that acclimatization is vital to the prevention of exertional heat illness. This can be accomplished through a gradual increase in practice intensity and equipment worn, as well as modifying the work-to-rest ratio to include more practice breaks.

That said, a number of factors contributed to the tragedy at Maryland before the May 29 practice even began. The workout had been scheduled to take place inside the university's football stadium, but construction forced a late move to practice fields. Indoor practice was ruled out due to inadequate field space, according to Walters, who added that athletic trainers had to "rush to get hydration products and other emergency equipment to the synthetic turf practice field."

Players were given a gallon of water to drink before practice, but McNair, who had consumed only a bowl of cereal that day, left his gallon unopened in his locker.

Among the athletic training staff's major shortcomings on May 29 was the failure to administer a cold plunge to McNair upon the first signs of heatstroke. Athletic training staff members feared their relatively small stature put McNair at risk of drowning during transition to a plunge pool.

The Washington Post reported Sept. 21 that medical experts have said that patients have a 100 percent survivability rate when heatstroke is treated promptly and the body temperature is lowered within 30 minutes. The Walters report clearly states, "Cold-water immersion is the most effective means to treat a patient with exertional heatstroke." According to hospital records, McNair's temperature reached 107 degrees and wasn't lowered to 102 until 7:20 p.m. — two hours and 27 minutes after McNair first reported cramping and 90 minutes after McNair began yelling at athletic trainers in the Gosset Athletic Training Room, an indication of a change of mental status consistent with exertional heatstroke.

Other disturbing issues came to light in the Walters report, including an apparent callousness on the part of head athletic trainer Wes Robinson, who witnesses say shouted, in reference to McNair, "Tell him to get the f*** up" during the workout and that players should "drag his ass across the field." Players interviewed for the report described a lack of trust between players and football staff, and that "The Pit" — where players go during practice when injured — was to be avoided at all costs.
 

Immediate concerns
On July 27, a week after visiting College Park, Walters shared five immediate concerns with Maryland senior administrators in the hopes those concerns would be addressed ahead of the pending football practice season:

1. The injury evaluation did not include any assessment of vital signs. Specifically, core temperature was not established, which ultimately is a critical part in identifying a rapid decline in the athlete's physical state.

2. Treatment provided did not appropriately address the escalating symptoms of heat-related illness. The pre-hospital care of exertional heat illness should include rapid recognition and treatment of signs and symptoms associated with this condition. No vital signs were noted, including core temperature.

3. No apparatus was used for prompt cooling of the patient on May 29. This is discussed in the literature as best practice and needs to be part of the University of Maryland Sports Medicine Services Staff Manual. The current procedures do not include core temperature assessment but do include aggressive cooling in the event of an identified exertional heat illness.

5. Once the patient's condition deteriorated and respiratory aids were needed, the trauma bag had to be retrieved from the practice area as equipment (manual suction or oxygen) was not available in the Gosset Athletic Training Room.
 

Action plan lacking
The report acknowledges that the University of Maryland Sports Emergency Action Plan meets guidelines, but the EAP was not initiated in response to McNair's escalating symptoms of exertional heat illness on May 29. In fact, Walters found that staff failed to implement established best practices well before the onset of tragedy. "There is no evidence or documentation of training and practice of the EAP," the report states. "Specifically, when interviewing Assistant Strength Coaches on August 2, 2018, there was no recall of EAP training for their staff."

Critical components of the EAP are communication and practice, according to the report, which states, "There should be detailed sessions of education, training and practice specific to the EAP. This must be orchestrated and appropriately planned for all parties involved in care, including coaches and administrators. All training sessions should be logged and recorded if possible to allow further review and creation of plans to address deficit or negligent care areas."

It goes on to add, "The inclusion of a coverage model requires the creation of a document description of roles, expectations and implementation of the EAP. It also allows for training plans and validation of the educational process. The EAP is critical to emergency care. The coverage model should be a written understanding of all roles and responsibilities of personnel relative to incidents occurring within the department. The coverage model provides a document of understanding for administrators, coaches and healthcare providers specific to responsibilities related to emergency incidents."

To that end, the plan must be communicated to all relevant parties, "including the care team, local police, fire fighters, EMS and administrators," the report states. "This should be a living document with updates as indicated specific to facility modifications, construction or other impending situations."

Walters adds that the EAP should identify emergency equipment that may be needed for appropriate care, including the location of the equipment. AEDs, for example, should be strategically located to ensure a three-minute response time. Moreover, the EAP needs to identify a clear method for communication to the appropriate emergency care providers and identify the mode of transportation that should be requested for an injured patient. Hospitals for referral of specific injuries or illness should likewise be part of the EAP. A staff person should be sent to meet EMS, something the Maryland EAP called for but athletic trainers failed to execute.

Radio communication equipment, required at all practices by the University of Maryland Sports Medicine Services Staff Manual, wasn't available the day of the incident. An athletic training kit, emergency phone numbers and student-athlete emergency information, water and ice are additional provisions called for by the Manual.

The following items were reportedly included in the trauma bag utilized on May 29: an AED with backup pads, an oxygen tank, oxygen masks, an EpiPen, an inhaler spacer, glucose tablets and gel, a blood-pressure cuff, a stethoscope, a pulse oximeter, gloves, sterile gauze, a thermal blanket, CPR masks, artificial airways, scissors, a bag-valve mask, manual suction, a peak flow meter, a cervical collar, a razor, towels and copies of EAPs.

However, Walters' report recommends that the following items be added to the list: a tub suitable for cold-water immersion, rectal thermistors and access to "copious ice" onsite.

For a profession that faces the potential for catastrophic injury, there's no such thing as being too prepared, and no eventuality can be overlooked. The Walters report makes that clear. Hopefully, McNair's tragic outcome is the last of its kind at Maryland — and anywhere athletic trainers, no matter how challenged by circumstance, are entrusted with human life.

This article originally appeared in the November | December 2018 issue of Athletic Business with the title "Report outlines mistakes in McNair tragedy." Athletic Business is a free magazine for professionals in the athletic, fitness and recreation industry. Click here to subscribe.