More than an hour passed between the time University of Maryland football player Jordan McNair started displaying initial heatstroke symptoms and when university officials called 911, sports medicine consultant Dr. Rod Walters said at a news conference Friday.
During a closed session meeting at Towson University, the University System of Maryland’s governing body reviewed the findings from an external investigation into the death in June of the 19-year-old offensive lineman. Walters, head of the sports medicine consulting firm Walters Inc., then presented the findings of his 74-page report to the news media.
University leaders have already said the care they provided McNair, a former McDonogh School standout, was not consistent with best practices.
The athletic training staff did not take McNair’s temperature and did not use a cold-water immersion treatment, a technique researchers say has a high success rate for those suffering heatstroke.
University President Wallace Loh previously said the school takes “legal and moral responsibility for mistakes the training staff made” on the day McNair was hospitalized.
Walters’ review found that cold-water immersion tanks are generally part of the field setup at Maryland, but they were not there on May 29 because the football practice switched locations at the last minute. It was moved from Maryland Stadium to the practice fields.
“Although change of venue is not uncommon in outdoor sports,” the report states, “it is essential that sufficient time must be allowed to ensure minimal medical equipment is set up by the athletic training staff prior to practice initiating.”
The Walters review provides the most detailed timeline to date of what happened at McNair’s final practice.
The conditioning session began at 4:15 p.m., and hydration stations were placed around the field. Five certified athletic trainers were on the turf.
The players began making their way through 10 rounds of 110-yard runs. McNair finished the first seven runs within a normal time. By the eighth round, the trainers noticed he looked “exhausted.” His cramps and exhaustion were reported at 4:53 p.m.
By the final repetition, McNair was struggling, so his teammates “went to run with him and encourage him to complete the repetition,” the report states.
ESPN reported previously that other players had to help McNair finish the workout and when the 10th sprint concluded, football trainer Wes Robinson yelled, "Drag his ass across the field!"
That account was backed by anonymous student interview notes included in the report. Walters’ team interviewed four student-athletes, whose identities were protected.
One player said Robinson yelled across the field to “get him the [expletive] up.” Another student said McNair could barely stand but was “walked” back to the drills, a reflection of the coaches’ “no-quit mentality.” A third player echoed that Robinson had shouted for McNair to “drag his ass across the field.”
The final student-athlete who was interviewed told the Walters team that McNair was “bending over at the waist” by the eighth repetition — “a no-no with coaches.”
Just before 5 p.m., athletic trainers began caring for McNair on the field.
Trainers reported him suffering from fatigue, back pain, cramps, hyperventilation and profuse sweating.
At 5:22 p.m., McNair was taken to the football field house — about 30 minutes passed between the onset of symptoms and the time he was removed from the field.
Once in the field house, McNair was placed on a large mat with his legs elevated. He reported back cramps and feeling uncomfortable. The assistant athletic trainers were told to get cold towels to cool him down.
While the trainers worked to hydrate McNair and cool him with towels, he had a “drastic mood change” and began yelling — another sign of heatstroke. McNair then suffered a seizure.
The trainers called the head physician, who told them to call 911. They did so at 5:55 p.m., more than an hour after McNair first started showing symptoms on the field.
Another 911 call went out at 6:02. McNair left for the hospital in an ambulance at 6:27 p.m.
When Walters asked the head football trainer why the training staff didn’t use a cold whirlpool to treat McNair, he said there was a concern about the offensive lineman’s large size relative to the smaller trainers.
“There was a fear of [McNair] drowning,” the report states.
Cold-water immersion would have been more effective, Walters said at the news conference.
“That is best practice,” he said. “That didn't happen that day."
The report found the university’s “failure to rapidly recognize exertional heat illness is a concern.”
“The lack of recognition and assessment of the severity of the event delayed cooling the patient in a timely manner,” the report said.
When the severity of McNair's condition eventually was identified, "inadequate cooling devices were used in place of cold-water immersion or cold whirlpools."
When asked if this case displays negligence, Board of Regents chair James Brady said he was “not in position to make that call at this time." He added that he wants to gather more facts before making a judgement call.
Murphy, Falcon & Murphy, the law firm representing McNair’s family, received a copy of the report late Thursday, but did not respond to a request for comment.
Loh also received the report Thursday night. He said the university didn’t wait until the report was completed before beginning to implement Walters’ list of recommendations.
“Even though the final report did not come in until today, [Walters] was spending a lot of time here,” Loh said. “And he was providing us with preliminary observations and also making recommendations and being involved in enhancing the training and our commitment.
“I said to him, ‘What I want are recommendations to make sure that this tragedy never happens again, that we do everything possible for the safety and well-being of our students.’ There were a whole bunch of things that we started doing since, I would say, early July.”
Some of those changes involved conditioning and training procedures, Loh said. The university increased the number of medical training staff and added on-site cooling stations, and also held additional training on the emergency action plan for athletics staff, among other improvements, he said.
Head football coach DJ Durkin declined to comment on the Walters report through his attorney.
Durkin, Robinson and Steve Nordwall, who oversees the trainers and strength and conditioning coaches, had been placed on paid leave after another ESPN report on Aug. 10 said Maryland’s football team fostered a “toxic” culture. Strength and conditioning coach Rick Court also was placed on leave before submitting his resignation.
The school launched a separate investigation into those claims being overseen by the Board of Regents. Among the eight people commissioned to review the team’s culture are former Gov. Bob Ehrlich, Tom McMillen, a former U.S. congressman and Maryland basketball star, and retired U.S. District Court judges Ben Legg and Alex Williams. That investigation is ongoing.
No personnel decisions were made Friday and none are expected until the completion of the second investigation.
The Prince George’s County state’s attorney’s office is continuing to monitor the situation.
“We will need time to review everything before making a decision on whether or not there is evidence to sustain criminal charges,” said spokesman John Erzen.
The Walters Inc. review came a day before the Terps will face Minnesota at home in their Big Ten opener.
Brady said the report doesn’t change the tragic outcome, but it highlights a path forward.
“Dr. Walters has presented a litany of recommendations that we want to implement not only at College Park but at all of the other institutions in the system that have football programs,” he said. “I wish we could say that we could bring Jordan McNair back to life. That would be the greatest thing that we could possibly do. That cannot be done. And the tragedy that the McNair family has to deal with cannot be overcome.”
But, Brady said, the university can use the experience to make safety for student-athletes “much better and more focused than it might have been in the past.”
University System of Maryland chancellor Robert Caret echoed him.
“You can’t repair the past. You can only hope to improve the future,” he said. “You do wish they had made different decisions at that point in time.”
Baltimore Sun reporter Don Markus contributed to this article.