It’s 7:30 on a Sunday evening. You and your partner are responding to a call for an unconscious patient in a local nursing home. It has been a hot, busy shift so far. In fact, the temperature in the last few days has been in the mid-90’s with high humidity. The weather stations have been saying we are in the middle of a heat wave.
As soon as you enter the five-story building, which has approximately 40 residents on each floor, you notice it is way too hot inside the building. You are led by an aide to a patient’s room, and you can’t help but notice there are quite a few patients who will need to be evaluated.
At this point you begin to call for a supervisor and additional units. Your partner peeks in a few rooms and notes most patients are a bit overdressed for the heat. Also, they are restrained in their beds making it difficult to hydrate themselves.
You both note there are no staff or visitors anywhere to be seen. The aide shares that the air conditioning for the building has been broken for the past two days. The windows do not open for safety purposes and there are a couple of large fans, moving hot air at the end of the hall.
After arriving at your patient’s side, you begin your primary survey and start removing the restraints and one patient’s flannel night gown.
You and your partner decide it is time to notify dispatch this is going to be a mass casualty incident (MCI). Supervision, additional EMS units, police, and the fire department should respond.
Ultimately, rather than transporting all the patients, the fire department broke some windows and brought in real fans. The mobile emergency room van (MERV) responded with medical staff, and every one of the patients was properly evaluated, cooled off and hydrated. In all there were 18 patients transported to hospitals, including two who ultimately died. One 84-year-old had a temperature of 107 Fahrenheit. The other 182 patients were treated throughout the evening.
This story begs the question as we move into the summer months: Are you prepared for a heat wave? Are your students? Read on to learn how to get your EMS students ready for what will inevitably be a scorching summer season across the country.
Background on Heat-Related Injuries and Deaths
Heat waves, defined as three-plus days of 90-degree weather or above, can be critically dangerous for those without access to air conditioning. The news has been littered with headlines about heat related calls increasing. In 2022, a heatwave in Europe yielded one-heat related call every 13 seconds. Heat-related calls in the South are increasingly common. Calls surged during the first half of summer 2022 in Austin, Texas. There were similar reports in 2022 everywhere from Boston to San Diego and several points in between.
During 2004-2018, an average of 702 heat-related deaths (415 with heat as the underlying cause and 287 as a contributing cause) occurred in the U.S. annually, according to data from the CDC.
When the CDC analyzed mortality data from the National Vital Statistics System (NVSS), these patterns in the rate of heat-related mortality were found:
- The rate was higher in males (approximately two thirds of all deaths).
- The rate was higher in persons aged 65 or greater years and involved 40 percent of all heat-related deaths.
- The rate was higher in non-Hispanic American Indian/Alaska Natives, and
- The rate was higher in noncore nonmetropolitan and large central metropolitan counties.
With anticipated increases in temperature each year, it is more critical than ever to re-evaluate how and when we teach proper techniques for EMS and fire professionals when treating individuals suspected of suffering from heat-related illness.
Heat-Related Illness: Risk Factors, Types & Comparison
Factors that increase a person’s risk for the ill effects from heat stress include:
- Increasing internal heat production—for example: physical exertion, infection/fever, hyperthyroidism, agitated and tremulous states, certain drug overdoses.
- Interfering with heat dissipation—for example: high ambient temperature, high humidity, obesity, impaired vasodilation, diabetes, alcoholism, certain drugs, impaired ability to sweat, heavy or tight clothing.
- Increased heat absorption—for example: confined unventilated hot living quarters, working in hot conditions, being in non-airconditioned parked vehicles in high temperatures.
- Impaired body response to heat stress –for example: dehydration, prior episode of heatstroke, hypokalemia, cardiovascular disease, previous stroke or central nervous system lesion.
The major types of heat illness seen in the field include: heat cramps, heat exhaustion, and heatstroke. Let’s compare these three:
- Heat Cramps – These are acute, involuntary, painful muscle spasms in the lower extremities, abdomen, or both. They occur because of profuse sweating and the sodium losses it causes. Three factors contribute to heat cramps: salt depletion, dehydration, and muscle fatigue.
- Heat Exhaustion – This heat illness is classically described as either water-depleted or sodium-depleted heat exhaustion.
Water-depletion occurs primarily in geriatric patients and is made worse by: immobility, medications that contribute to dehydration and decreased thirst sensitivity. The symptoms can be nonspecific and may include: headache, fatigue, weakness, dizziness, nausea, vomiting and abdominal cramping.
Sodium-depleted heat exhaustion is due to an acute decrease in serum sodium concentration during the 24 hours after prolonged physical activity. These patients have too much water in relation to total sodium and may be diagnosed with exercise-associated hyponatremia (EAH). EAH is not always symptomatic and is diagnosed by checking blood sodium level. When symptomatic it can result in death if left untreated. The symptoms can range from headache, nausea and vomiting to confusion and seizures. Cerebral edema, noncardiogenic pulmonary edema, respiratory distress and coma can occur.
- Heatstroke – This is the least common but deadliest heat illness causing severe disturbance in the body’s thermoregulation. Diagnosis depends on elevated core temperatures and altered mental status (AMS).
Described as either classical or exertional heat stroke. Classical heatstroke is common to heat waves due to combined high ambient temperatures and humidity. Exertional heatstroke is usually a younger patient exercising in hot and humid conditions where the body loses its ability to shed heat through radiation, convection, and evaporation.
Assessment & Management Teaching Tips
Teach your students to assess the patient in a safe place, out of the direct sun.
- Sit or lay the patient down in a comfortable position.
- Conduct a Primary Survey or “XABCDE” check (eXsanguinating hemorrhage Airway, Breathing, Circulation, Disability, Exposure) for potential life-threats and manage if found. PHTLS: Prehospital Trauma Life Support, Tenth Edition features key information on teaching this approach.
- Determine the patient’s mental status. If altered, consider the causes of AMS. This is not just a heat check. Instruct your students to check the patient’s blood sugar, as an example.
- Obtain a complete set of baseline vitals. If patients are hot to the touch always take their temperature. If there are any irregularities or if the patient complains of chest pain, obtain a 12-Lead ECG.
- Get a good sample history, especially a list of any medications the patient is taking.
- If you suspect heatstroke due to an elevated core body temperature (CBT) and AMS:
- Begin cooling the patient right away. Research shows that cold-water immersion is the most effective technique for rapidly reducing the CBT and should be started as soon as possible. Use a kiddie pool or tarp-improvised pool to immerse the body from the neck down in cold water.
- Reassess the temperature as you want to bring the CBT to < 102.2F or until neurologic symptoms have resolved.
- Be prepared to manage seizures. Be cautious with IV fluids as pulmonary edema is a complication of heatstroke.
- Monitor cardiac rhythm.
- Take serial vital signs and determine appropriate transportation destination considering hospital status due to heatwave conditions.
- Consult with medical control prior to transportation decision of the heatstroke patient.
- If you suspect heat exhaustion:
- If the patient is alert and will swallow small amounts of water or electrolyte fluid, that can be helpful.
- If the patient is dehydrated and is not able to drink or has an altered mental status, begin IV fluids per protocol.
- If you suspect heat cramps and they are alert and able to drink, consider electrolyte fluid and massage leg muscle cramps.
Preparing for This Year’s Heat Waves
Heat-related death is preventable in most cases. The CDC concluded that a coordinated approach across health care sectors to prevent heat-related mortality includes: conducting syndromic surveillance, developing and implementing heat response plans, facilitating communication and education activities, and operating cooling centers.
As first responders, we should have a seat at the table when planning for heat waves. Our role in each key step is preventing these unnecessary deaths, as well as being prepared to respond, assess, and manage the patients affected by the heat in our community.
Strategies for your agency to prepare for heat waves should include:
- Monitor the local weather conditions every few hours and communicate with providers as necessary. Staff additional EMS personnel to address the anticipated increase in demand.
- Public Information Officers should be prepared to providing heat emergency education for the public and media.
- Review your inventory—Consider which supplies you do not have. Be sure to include fluids to hydrate, coolers with bags of ice, thermometers, and access to kiddie pools for field cooling.
- Review the policy on dealing with power outages and backup communications equipment.
- Know where the community cooling centers will be set up, and if your agency can transport to a cooling center if medically cleared.
- Review the procedures for medical standby in rehab sector at fires and rescues during the heat wave.
- Consider acceptable, safe, yet practicable heat wave uniforms for your personnel (i.e.: loose-fitting, light-colored clothes).
- When working outside an air-conditioned area for long periods of time, consider the need to rotate personnel and adequately hydrate.
- Review policies on check-ins with known at-risk residents and family members.
- Review the treatment protocols for heat-related emergencies.
- And on a personal level, let your family and friends know how you have prepared for severe weather and help them become weather ready.
As we cannot change the weather, we can plan for its extremes. A good starting point would be to pay attention to the weather reports from a reliable source in your community. Check out the Climate Prediction Center from the National Weather Service, for example.
In the preparation of medical standby for special events such as large gatherings, concerts, firework displays, etc.) consider extreme weather plans. In the specific case of endurance sports events (marathon, Ironman triathlon, century bike rides, etc.) keep in mind that the athletes trained for the normal weather in your community on the day of the competition. If on the day of the event the temperature is considerably higher/lower than expected, it will have an effect on their performance and may lead to larger than normal numbers of casualties. Your medical plan for the event should address the weather extremes such as a heat wave such as cooling stations, additional medical support and the possibility of reschedule or cancelation.
Nancy Caroline's Emergency Care in the Streets, Ninth Edition includes the most current scientific recommendations developed by the International Liaison Committee on Resuscitation (ILCOR) and the ECC Guidelines established by the American Heart Association and other resuscitation councils around the world. Download a digital review copy in consideration of course adoption.
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About the Author:
Bob Elling, MPA, Paramedic (retired) has been a career paramedic, educator, author, and EMS advocate since 1975. He was a paramedic with the Town of Colonie EMS Department, Times Union Center, and Whiteface Mountain Medical Services. He was an Albany Medical Center Clinical Instructor assigned to the Hudson Valley Community College Paramedic Program. He has served as National and Regional Faculty for the AHA and was involved in many successful life-saving legislative campaigns with the You’re the Cure Network. He also served as paramedic and lieutenant for New York City EMS, paramedic program director and associate director of the New York State EMS Bureau. He has authored hundreds of articles, videos, and textbooks to prepare the EMS provider for their career. Bob is the ECSI Medical Editor for CPR and First Aid Series of products and the Co-Lead Editor of Nancy Caroline’s Emergency Care in the Streets.