This month's death of four high school football players in the heat-stricken South is helping to spotlight a current recalibration of how much physical exertion young athletes can endure, one change in what is a broader effort to minimize their risk of injury and illness.
For its part, the Arkansas Activities Association now orders coaches to complete online courses in heat-related illness, which has been cited but not conclusively linked to the Aug. 1 collapse of a 15-year-old Arkansas football player with an underlying heart problem that had gone undiagnosed. He died shortly after collapsing.
Arkansas coaches also must undergo training in methicillin-resistant staphylococcus aureus, MRSA, a type of staph bacteria that does not respond to antibiotics that have been commonly dispatched to treat staph infections. Since at least the early 2000s, schools across the country have reported outbreaks of that potentially deadly infection, spread largely through skin-to-skin contact.
In 2003, a Centers for Disease Control report spotlighted outbreaks of the disease in California, Colorado, Indiana and Pennsylvania.
Last year in Arkansas, one high school athlete died from the infection and another suffered a heart attack.
"He's permanently disabled, in a wheelchair. He has a [tracheotomy tube], and very limited mental capacity," said Dr. Jimmy Tucker, a sports medicine specialist in Little Rock.
More immediately, forecasts that the South's heat wave will extend through September have affirmed the state's recent move to limit two-a-day practices -- especially during extreme heat, when the body requires up to 48 hours to rehydrate -- to every other day and any single practice session to no more than three hours.
Even southern kids are less acclimated to hot spells than during prior generations were, what with many of them spending more time indoors rather than outside, said Tucker, a member of the state activities association's sports medicine advisory board.
In keeping with that, other rules, patterned partly after the NCAA, also require high school players in Arkansas to weigh in before practice and weigh out afterward.
"If they've lost three or four pounds, that's strictly water and they absolutely have to rehydrate," Tucker said.
"The symptoms of heat-related illness are pretty dramatic," he added. "Usually it starts with disorientation. They get lethargic and confused. They're not sure where they're at or what they're doing. They stop sweating. They have trouble breathing, and it progresses to the point where they're going to faint, and they actually go into arrest. Heat strokes are fairly deadly."
The 2001 heat-stroke death of Minnesota Viking Corey Stringer put that risk on the radar, said Tucker, adding that the Indianapolis-based National Federation of State High School Associations has been particularly diligent about pushing safety reforms.
"Almost all the states have instituted new controls," Tucker said.
Parents also play a role. They must ensure, for example, that their kids are properly hydrated, aware that heart palpitations and shortness of breath can signal a serious heart condition and, more than that, know their own family's medical history.
Kids with a close relative who died from a heart attack or stroke before age 50 may have a hypertrophic cardiomyopathy, an often genetic thickening of the heart muscle, that constricts blood. Black athletes suffer disproportionately from that defect, Tucker said.
Athletes sometimes misread the warning signs, said Dr. Eric Gordon, another sports medicine specialist in Little Rock.
"If the heart is racing out of control, if it's beating funny, if it feels like a rabbit's in your chest, even for a split second," a thorough medical exam may be necessary, he said. A roughly five-minute electrocardiogram can determine the extent of the problem, Gordon said.
Short of high schools paying for that test, which they don't routinely do in Arkansas, the state has adopted a much more extensive questionnaire on the health of a student and his or her family.
"The prior questionnaire was real rudimentary," Tucker said. "Almost not much more than simply signing your name on a sheet of paper."