Use of IVs to hydrate high school football players sparks controversial debate

The Atlanta Journal-Constitution surveyed more than a dozen high-profile GHSA football programs and found that there are a handful of schools that use the method -- most in the deep south area of the state. Only two schools — Colquitt County and Thomasville — were willing to speak on the record about their process. A few others declined, fearing controversy.

The high school program at Thomasville has become the epicenter of the IV debate. Chip Clatto, the school’s former principal whose contract was not renewed after a school board vote in February, has been critical about the IV process the Bulldogs’ program is using. On Tuesday, Jacksonville's First Coast News reported that the Thomas County chapter of the NAACP has demanded the resignation of Thomasville City Schools superintendent Laine Reichert and Bulldogs coach Zach Grage because of that process.

Using the IV method

Colquitt County is a Class AAAAAAA powerhouse program located in Moultrie, 200 miles south of Atlanta. The program is led by one of the most accomplished high school football coaches in the country, Rush Propst, who is in his 11th season with the Packers. He has won seven state championships — two with the Packers and five in Alabama as coach of Hoover High — during a career that dates to 1989, when he coached Ashville (Ala.).

The IV method is nothing new to Propst, and each of his programs have used it, from Ashville to Colquitt County.

“We’ve been using IVs for our kids since the mid-80s,” Propst said. “It’s just being smart and preventative.”

Although the Packers use the IV method, it’s not their first option. In fact, they rarely use it. Long before an in-game situation, where the method may be considered as necessary, the medical staff spends summer practices evaluating their players. Dr. Kevin Collins, who serves as the head orthopedic physician for Colquitt County and Valdosta State, and who is a partner at Hughston Clinic, said they follow the hydration protocol recommended by the National Athletic Trainers’ Association.

“It’s basically multi-fold,” Collins said. “We counsel each athlete on how sensitive they are to hydration.”

While evaluating players in the summer, the staff identifies players who experience varying levels of cramping and monitor them, tracking how much fluid they lose, studying urine consistency and identifying their risk for dehydration. They then assign an individualized plan for those players, and that has eliminated most of the need for the IV method.

Collins said the football players needed IVs during games only twice.

“One was an athlete who was vomiting and had suffered from a gastrointestinal illness midweek,” said Collins, who is board certified in sports medicine and orthopedic surgery. “We cleared him to play, but he was dehydrated and complaining of thirst and discomfort. In another instance, one that sticks out from last year (Colquitt County’s 3 p.m. game in the Kell Classic at Georgia State), we did an IV for a heavy sweater, who we knew was prone to cramping.”

Collins leads a team of seven medics employed by the Packers, including head athletic trainer Ryan Keebler, in his ninth season with the team, and Dr. Gary Swartzentruber, the team’s family physician. Collins said either he or Swartzentruber will make a determination during a football game whether a player needs in-game IV treatment for hydration.

Keebler estimates the Packers have used IVs to treat players for hydration during games less than five times since 2013.

The most common instance where an IV would be used during a game is cramping, Collins said. But first, the team will first try oral hydration, or drinking fluids. If there’s still break-through cramping, IV treatment becomes an option.

“That’s not really a problem with us, though,” said Collins, “partly because of how we condition our kids starting in the preseason and throughout the week.”

There are other instances where an IV may be considered besides cramping. Maybe the player is thirsty but is sick and having difficulty holding down liquid. Examples include gastrointestinal cramps or vomiting. A player may also become a candidate for IV treatment if they’re still suffering from those symptoms as late as the Wednesday or Thursday leading into Friday’s game. Again, these are circumstances Collins said he hasn’t encountered with his players but are ones that would call for IV treatment.

When IV treatment is administered during a game, it can be done in 10 minutes with the use of a standard-size needle. The bag consists of a saline-glucose solution. After an athlete is hydrated by a member of the medical staff, the player is checked to ensure his urine color is normal and that his cramping symptoms have been resolved. After a brief warmup period, he’s cleared to resume playing.

Collins notes that before a Packers player is eligible for IV treatment, or any other medical treatment administered by team medics, a parent or guardian must sign a consent form.

Credit: Casey Sykes

Credit: Casey Sykes

Thirty miles south of Colquitt County, a branch of the Propst coaching tree resides at Thomasville High, where Grage is in his third season leading the Bulldogs. Although Grage came to Thomasville after a brief stint as Gilmer’s coach in 2015, he spent the previous six seasons as an assistant for Propst at Colquitt County, where he served as Packers offensive coordinator during their 2014 Class AAAAAA undefeated state championship season.

Grage has taken a lot of what he learned and installed it into the Thomasville program. The results thus far have been favorable, most notably in 2017 when the Bulldogs won their first 12 games and finished with their best record (12-1) since 1988. They advanced in the Class AA playoffs again this season.

He, too, is a proponent of the IV method for in-game hydration, and the Bulldogs take an approach that’s similar to the Packers.

“I’ve always said (Thomasville) is a mini-Moultrie,” Grage said. “Thomasville has pride, tradition and resources. One of the things I pushed for when I got here was to be on the cutting edge when it comes to nutrition.”

Grage said the Bulldogs have partnered with the medical staff at Archbold Medical Center and employ full-time athletic trainers for the team. While the Bulldogs have a nutrition plan in place that’s customized for each player, there are some who could need additional hydration treatment during or before games, including the IV method. As with Colquitt County, Grage said Thomasville has a parent or guardian of the player sign a consent form before receiving team-prescribed medical treatment

“We use (the IV method) for at-risk kids,” Grage said. “We have 13 kids who, at some point in the summer, were cramping, like kids with low body fat percentages whom we expected to play a lot and play both ways (offense and defense).”

For those kids, Thomasville has administered IVs ahead of games as a preventative measure against dehydration. Grage said the team began using the method in 2017 — his second year at the helm — and that it has been used a handful of games each season, although mostly toward the beginning of the year when weather is significantly warmer.

The Bulldogs most recently used the IV method on a game day hours before their regular-season finale Nov. 2 against Early County. Grage said, in most cases, the method is used for home games because traveling with the IV bags becomes an extra burden, although before the Bulldogs’ game at Crisp County on Sept. 28, players appeared to have been given treatment while on the team bus.

First-resort hydration strategies

Both the Packers and Bulldogs say the IV method is either the last-resort option or one that’s seldomly used, and that they use other, more traditional methods to keep their players hydrated. Some GHSA coaches, who said they don’t use the method, also spoke about hydration strategies.

For the Packers, Collins said dehydration is, for the most part, preventable. But Colquitt is one of the country’s best-funded public schools and has resources that most South Georgia schools do not. For example, Colquitt has an indoor practice facility that allows players to avoid practicing in heat throughout the week. Schools that don’t practice indoors must follow the GHSA policy for heat and humidity, which most notably requires the use of a scientifically-approved instrument that measures the Wet Bulb Globe Temperature, which detects extreme heat and/or humidity levels and determines if it’s safe to practice.

Much in the way teams prepare for their opponent by installing a game plan throughout the week, teams also prepare from a hydration standpoint. It’s not enough for a player to drink plenty of fluids on game day, or even the day before. Preparation begins much earlier in the week, and diet and nutrition play a vital role.

“I had a player tell me once that he hasn’t had a Coke in four years,” Collins said. “We try to steer them toward electrolyte-based fluids, like Gatorade, and stuff that’s good for them.”

Collins, who is also the team physician for Valdosta State football, admitted it’s more of a challenge for him to have collegiate players follow nutrition protocol than at the high school level.

“They’re wanting to drink beer on Fridays and then play on Saturdays,” Collins said.

Propst said they feed the team at school for as many meals possible to help ensure they’re following a healthy nutritional regimen. He said the team eats together on Saturday, twice on Sunday and four times a day, Monday through Friday.

“To me, that’s helped most with hydration issues,” Propst said.

“We feed our kids as much as we can,” Grage said.

Alan Rodemaker, coach of another deep south, traditional power — the Valdosta Wildcats — said some of his players drink 5 ounces of XRCEL, a carbohydrate supplement, before each game and during halftime, in addition to the nutrition regimen the team follows throughout the week. Troup uses Pedialyte on game morning, Powerade at lunch, and Biolyte during pregame and halftime, Tigers coach Tanner Glisson said.

The general consensus is that hydration is a process that begins much earlier in the week. Greg Taboada, who played tight end and defensive end at Marist from 2010-13, then tight end at Stanford from 2013-16, said that when he was at Marist, they followed a weekly regimen.

“We really started with the hydrating and sleep schedule on Wednesday because it takes two days for the cycle to set in,” Taboada said. “It was no special secrets, just things like drinking water and not stuff that has sugars. But it’s important that you’re hydrating in the days before game day, because if you just pound water on Friday, you’ll just (use the bathroom and it will be gone) immediately.”

Taboada said that for in-game hydration, Marist provided pickle juice and salt tablets.

“They tasted terrible,” Taboada said of the tablets. “But if you were known as a chronic cramper, or you were playing both ways, or if it was extra humid that day, take one before the game.”

Credit: Drew Dinwiddie

Credit: Drew Dinwiddie

The NFL and NCAA

According to a 2011 study published in the Clinical Journal of Sports Medicine, 75 percent of NFL teams used the IV method for pregame hydration. On average, five to seven players per team received this treatment, and the most common reason cited was muscle cramps. The primary reason it was administered was due to player request.

In 2013, the same publication released a similar study regarding the NCAA football, surveying 120 programs and finding that 77, or 64 percent, reported pregame intravenous fluid hyperhydration (PIVFH). Thirty percent of the programs that used PIVFH reported that it was administered to only two to three players. Again, the most common reason for use was muscle cramps (95 percent), although heat illness (79 percent) and dehydration (68 percent) were also listed as common reasons. Forty-Seven percent of uses came at the request of the player.

Unlike the NFL study, however, the NCAA study showed that PIVFH was administered in 47 percent of the cases to “improve exercise tolerance,” and 15 percent of the of those believed it improved the team’s overall performance. This would put the IV method in performance enhancing territory.

Collins, who works at the Division II level as Valdosta State’s lead physician, said the current consensus among medical experts is that the IV method doesn’t create a competitive advantage.

“Right now, there’s no literature that supports any increased performance by using IVs,” he said. “That includes pregame, during or after, in a patient that can tolerate oral fluid. ... I can’t think of anyone, from a performance standpoint, who has benefited from using (the IV method) pregame.”

In his four years playing for Stanford, Taboada never saw a player being administered an IV before the game as part of a routine, although in special circumstances — like if a player who was sick all week had lost fluids or had suffered from food poisoning — its use was warranted. As was his case at Marist, hydration at Stanford came down to taking care of one’s self by following proper dieting.

“Our trainers could point out the guys who would probably cramp,” Taboada said. “It was usually a direct correlation to who showed up late for meetings, didn’t warm up. ... It was always the same guys. It’s not rocket science. You just have to be disciplined.”

Resistance to the IV method

The IV method at the high school level has been met with its share of criticism and resistance. The GHSA’s official stance, when reached by the AJC, was that it “lets the doctors do the doctoring.” In the GHSA constitution and by-laws, section 4.63 prohibits performance enhancing substances.

As of now, there’s no evidence the IV method gives players a competitive advantage. However, the World Anti-Doping Agency considers it a prohibited method. In WADA’s International Standard Prohibited List, released in January of 2018, Prohibited Method No. 2 (M2) prohibits, “intravenous infusions and/or injections of more than a total of 100 ml per 12-hour period except for those legitimately received in the course of hospital treatments, surgical procedures or clinical diagnostic investigations.”

Collins said the Packers administer 1-2 bags during treatment — with one bag containing 1,000 ml of fluid, in 10 minutes. That greatly exceeds WADA limits of 100 ml per 12 hours. While the WADA standard isn’t bound by any legal authority — and teams that use IVs could argue that they first conducted a “clinical diagnostics investigation” — it might be something for the GHSA to consider in its by-laws, especially when only a handful of schools use the method and their competitors don’t.

While schools like Colquitt County can afford its own medical staff, others aren’t so fortunate. In most cases, schools rely on certified athletic trainers, who work on-hand during games but might not be in constant contact with the team throughout the week. Dr. James Crownover, who is board certified in sports medicine, and who has worked GHSA football games since 2013 at Sprayberry and, currently, Westside-Augusta, notes the extensive amount of research on the front end that teams must do on each player before considering the IV method.

“You have to take into account an individual’s electrolyte levels and that each player is in their own physiological state,” Crownover said. “There’s definitely a risk if you don’t know what you’re doing, as far as electrolyte issues and heart rhythm problems. To me, the risk-reward ratio doesn’t make a lot of sense.”

One of the potential risks that came to mind for Crownover was hyponatremia, when the sodium in one’s blood level becomes abnormally low, which can occur from over-hydrating. In that case, the body’s water level rises, and cells begin to swell, which can lead to health problems ranging from nausea and vomiting to seizures, coma and even death, according to research by the Mayo Clinic.

In 2014, Douglas County football player Zyrees Oliver died of hyponatremia after drinking two gallons of water and two gallons of Gatorade. While he died hydrating orally, one could also over-hydrate via the IV method if not properly monitored.

There are also risks in the administration process. Although rare, should an air bubble form in the tube connecting the IV bag to the needle and then enter a vein, an air embolism occurs. These bubbles can travel to the brain, heart or lungs and cause a heart attack, stroke or respiratory failure, according to a medically reviewed article found on Healthline.com.

These risks and others that could potentially harm a player are enough for most schools to steer clear of the IV method.

“We have inquired with our school system about doing IVs, but we were told that we could not give them because it was a liability,” Glisson said.

Which again brings up the question of how necessary IV treatment is. The Lee County Trojans, who last year won the Class AAAAAA state title, played Westover in 2015 for a nationally televised game on ESPN that had a kickoff time of 11 a.m. During the game, high temperatures were expected to reach 101 degrees.

“We’ve never used the IV method,” Trojans coach Dean Fabrizio said. “But for (the Westover game) we had our team doctor and his staff of nurses in the locker room at halftime and after the game in case anyone needed an IV due to dehydration. No one ended up getting one though.”

Something else to consider: Sodium Chloride IV bags are on the FDA Drug Shortages list and classified as “Currently in Shortage.” Drugs are classified this way when its supply is inadequate to meet the current or projected demand at the user level, according to the FDA website.

“There are individuals who, in life-threatening situations, would benefit from IV treatment more than a starting football player,” said Karen Kelso, a registered nurse who formerly worked as HR director of Thomasville City Schools.

Taboada, along with a number of coaches who spoke off the record about the IV method, believes IV treatment could give players an out from having to follow strict nutrition guidelines.

“I think for high school kids, it’s an excuse not to take care of your body,” Taboada said.