In 2021, the International Olympic Committee's Adverse Weather Impact Expert Working Group published the most comprehensive international guidance to date on prehospital management of exertional heat stroke at sports competitions. Co-authored by researchers from ASPETAR Qatar, the Korey Stringer Institute, World Athletics, and sports medicine institutions across four continents, the paper in the British Journal of Sports Medicine defines what a competent event medical operation looks like. Here is what it requires — and what it means for the 2026 season.
Why international guidance exists
Heat stroke at elite sports competitions is not a theoretical risk. The 2019 IAAF World Athletics Championships in Doha, Qatar, were staged in conditions that tested the limits of sports medicine planning: 32°C with 73% relative humidity at 10:30pm during the marathon events. Twenty-eight of 68 starters in the men's marathon did not finish.
Dr. Sebastien Racinais, Director of Research and Scientific Support at ASPETAR Qatar Orthopaedic and Sports Medicine Hospital in Doha, co-organized the medical response. In a 2019 editorial in Frontiers in Sports, Racinais and Girard framed the stakes: heat stroke is "the second highest cause of death in sport after cardiac conditions" — and unlike cardiac events, it is entirely preventable and treatable if the right protocol is in place.
What the IOC consensus requires: five operational pillars
The IOC Working Group paper by Hosokawa, Racinais, Akama, Casa, Bermon et al. (British Journal of Sports Medicine, 2021) establishes five requirements:
1. Pre-event environmental monitoring A WBGT (Wet Bulb Globe Temperature) system must be in place before and during competition. Threshold values determine whether events proceed, are modified, or are postponed.
2. Early recognition across the course Course marshals, water station volunteers, and mobile medical personnel must be trained to recognize early neurological signs: confusion, disorientation, unsteady gait, inappropriate behavior. Any athlete who collapses during or after competition is a presumptive EHS case.
3. Rectal temperature as the diagnostic standard The IOC group is explicit: rectal temperature is the only field-reliable method for confirming or ruling out EHS. Ear, forehead, and oral thermometers are not adequate. Every course medical post and finish line tent must have rectal thermometers.
4. Immediate whole-body cold water immersion No alternative cooling method achieves the rate of temperature reduction required within the critical 30-minute window. The cooling equipment must be on-site — the IOC guidance does not contemplate a model where immersion begins at the hospital.
5. EMS coordination and transport protocol Medical evacuation is activated in parallel with cooling — not instead of it. Cooling continues during transport where possible. The receiving hospital is pre-informed of the patient's status.
Doha 2019: what a compliant operation looks like in practice
ASPETAR and World Athletics deployed pre-positioned cooling stations along all road race courses, medical personnel with rectal thermometers at every major checkpoint, and direct communication between course teams and hospital receiving teams. The outcome: no deaths, multiple EHS cases managed on site with full recovery. The difference between a fatal outcome and full recovery was measured in minutes — and in whether the right equipment was present.
The gender gap: a research deficit that matters
A 2022 paper in Frontiers in Physiology by Hutchins, Minett, and Stewart (Queensland University of Technology) raised an important point: the foundational research on cold water immersion effectiveness in EHS was conducted almost entirely on male subjects. Current guidelines are being applied to women without specific validation.
The practical implication is not to change the protocol — cold water immersion remains the best available treatment. But event medical directors should be aware that monitoring during immersion may need closer attention for female athletes, and that this is an active area of ongoing research.
What event medical directors must have in place for 2026
Equipment:
- Cold water immersion tub at every main medical post and at high-risk course points
- Rectal thermometers in every medical kit — minimum one per post
- Ice supply confirmed and planned, not assumed
Personnel:
- All medical volunteers briefed on EHS recognition and "cool first, transport second"
- Designated cooling coordinator at each tent with authority to initiate immersion without waiting for physician sign-off
Protocol:
- EHS response procedure written, distributed, and rehearsed before race day
- Threshold decision tree for weather-based event modification
- Coordination established with receiving hospitals before competition
Sources
- Hosokawa Y, Racinais S, Akama T, Casa DJ, et al., Prehospital management of exertional heat stroke at sports competitions: IOC Adverse Weather Impact Expert Working Group, British Journal of Sports Medicine, 2021 — pmc.ncbi.nlm.nih.gov
- Racinais S, Girard O, Editorial: Hurdling the Challenges of the 2019 IAAF World Championships, Frontiers in Sports, 2019 — ncbi.nlm.nih.gov
- Hutchins KP, Minett GM, Stewart IB, Treating exertional heat stroke: Limited understanding of the female response to cold water immersion, Frontiers in Physiology, 2022 — ncbi.nlm.nih.gov
- ASPETAR Qatar Orthopaedic and Sports Medicine Hospital — aspetar.com
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