How to be observant and proactive in helping patients endure warmer temperatures.
Exhausted after making a wrong turn and out of water, emergency physician Sarah Beadle, left her daughter and nephew, ages 10 and 11, alone in the shade on the basement floor of the Grand Canyon to look for help.
The children were later found alive by fellow hikers, given water and brought to safety only to later hear the shattering news that their mother/aunt had been found dead due to heat-related causes. The 2017 incident was another heat-related death. According to the CDC from 1999-2010, heat-related deaths in the US averaged 618 annually.(1)
With over 4 million visitors annually with the majority between April and September, heat-related injury and death at the Grand Canyon is a major concern. Hikers experience relatively mild temperatures at the rim, limited water along the way, extreme temperatures and easy downhill hiking to start. In one retrospective review of heat-related illnesses at the Grand Canyon between 2004-2009, EMS responded to 474 nonfatal and 6 fatal heat-related cases with the majority being US residents (84%).(2) Despite her knowledge and experience, the combination of harsh conditions and a wrong turn proved fatal for Dr. Beadle.
Heat related illness can be divided into two categories: Heat exhaustion and heat stroke. Heat exhaustion is categorized as dehydration, muscle cramping, nausea and vomiting, dizziness and weakness. Heat stroke is defined as a variety of neurologic symptoms including throbbing headache, confusion or altered mental status, agitation, seizures, slurred speech and even unconsciousness with a body temperature greater than 103F.
While the human body is able to cope with severe heat for a short period of time, exposure to extreme heat combined with dehydration and high humidity oftentimes proves fatal. When the body is unable to effectively cool itself through evaporation, risk for heat stroke increases. Risk factors associated with heat-related illness include extremes of age (less than 4 and older than 64), alcohol use, immobility, sudden change in outdoor temperature, lack of access to air conditioning, chronic medical conditions such as diabetes and exertion in hot and humid environments. Alcohol in particular is under-appreciated in its role of heat-related illness, as it promotes dehydration and can severely impair the body’s ability to regulate heat appropriately.
Most heat-related injuries take place during the warmer months with 94% occurring between May and September in the US with a peak in July. Heat waves have been known to place considerable stress on hospitals. A 2008 study out of California looked at a two-week long heat wave in the summer of 2006, which resulted in an extra 16,000 emergency department visits and 1,200 hospitalizations state wide (3). Injuries included simple dehydration, renal failure, electrolyte impairments and cardiovascular collapse.
During our busy shifts, it is often difficult to correctly diagnose the confused, agitated and febrile patient, but we must remember to hold a high index of suspicion for heat-related illness. For example, one presented to our department on July 4 as a “Code Stroke.” Per EMS, the patient was altered, minimally responsive and had slurred speech. Shortly after her arrival to our department, we discovered a core temperature of 107.6F. She was elderly, lived alone on the top floor of an apartment building, had no access to air conditioning and had a history of alcohol abuse. With a GCS of 3, the patient was intubated and both internally and externally cooled. Over the next 72 hours in the ICU, her clinical condition improved and she was extubated.
Although extremes of age are a major risk factor, a vigilant eye must also be kept on young athletes as they are at high risk for heat-related injuries. Summer months are often filled with training camps, summer leagues, and two a day practices. Combine this with extreme heat and humidity and the risk for injury is high. Heat stroke has been recognized as one of the most common preventable causes of death in youth athletes. A few statistics and perhaps a case to illustrate would be helpful.
Luckily, there are ways to mitigate the risk and help prevent heat stroke. It is our job as physicians to educate our patients on the risks associated with heat and what they can do to help prevent heat-related injuries such as wearing loose-fitting clothing, staying hydrated and avoiding exertion during the peak heat hours. Given the major role skin plays in heat regulation, it is important to allow the body the ability to cool itself through evaporation. For those who have no choice but to be outdoors, frequent breaks, adequate nutrition and hydration, and even a 10-minute escape to a cooled room regularly can help prevent heat-related illness.
Don’t overlook the dangers of heat for the safety of our patients, friends, families and ourselves outside the emergency department. Avoid exertion during hot and humid days and always be prepared to take breaks and hydrate. Even experienced hikers such as Dr. Beadle can succumb to heat related illness. Knowing the risks and management principles of heat related illness may help us avoid untoward events in the heat and help us to better manage our patients in the emergency department.
Contributing writer: Samir Patel, MD, is a Wilderness Medicine Fellow and instructor at Wild Med Adventures.