Case Study 5

The Answer


  • Possible heat exhaustion.

The Plan

  • Move patient to shade. Use cool wet compresses to lessen heat stress.
  • Hydrate and feed patient. Encourage small sips of water/electrolyte solution, roughly one liter/hour.
  • Take patient back to camp to rest for the remainder of the day. Position of comfort.

Anticipated Problems

  • Heat stroke, heat cramps, or hyponatremia

The Tale Continues

After listening to the SOAP report and approving the assessment and plan you check in on the other members of this trail crew. They are all tired and stressed by the heat, although none are as ill as the patient. One of the crew members has been feeling sick and has had a low-grade headache for a day. He thinks he has a “cold” and has been taking Sudafed. You’re concerned because this medication increases metabolic rate and is on the lists of drugs that can be problems in heat.

You learn the crew members have been drinking water, but the 3-4 liters daily recommended by the staff seems to be in reality 2-3 liters on average (the water has a brackish taste that no one likes). The work days are long and run from 8:00 a.m. until 6:00 p.m. It’s been warm in the evenings, the camp is noisy, and most of the crew members are sleeping poorly. You notice several of the boys have bandannas on their heads, none have long-sleeved shirts or wide-brimmed hats, and they all are red and bronzed from lots of sun exposure.

You decide to meet with your crew leaders and make some changes to manage this heat stress. First, you give everyone a rest day tomorrow and take them to a lake where they can swim and be cool. You can’t improve the water source so you try some drink mixes to entice the crew members to drink more fluid. You change the work schedule to early morning and evening shifts and make people rest in the shade in the heat of the day. And you tell them to wear loose, long-sleeved cotton shirts and hats to keep the sun at bay. Then you review strategies for preventing heat illness, predisposing factors, and the subtle signs and symptoms of heat stress.


The supervisor recognizes that prevention of heat illness is a leadership task before it becomes a medical problem. Leaders need to be alert for signs of developing heat illness in their groups. Environmental risk factors of high heat and humidity, coupled with dehydration, exertion, and overdressing, should raise caution flags. The vague symptoms of fatigue, headache, weakness, irritability, and malaise should be recognized as indicators of dehydration and heat illness.

Factors in the development of heat illness are the obvious hot and humid environment, increased heat production, decreased heat dissipation, and a lack of salt and water. Also on the list are age, general health, use of medications or alcohol, fatigue, and a prior history of heat illness. Patients with underlying problems (illness or injury) may not be able to tolerate heat. Underdeveloped physical mechanisms contribute to the incidence of heat illness in children. Individuals with compromised heart function are less able to adjust when stressed by heat. A study conducted by the U.S. Army demonstrated a correlation between lack of sleep, or fatigue, and the development of heat illness.

Antihistamines, antipsychotic agents, thyroid hormone medications, amphetamines, and alcohol are among the drugs that have been implicated in the development of heat illness. Some interfere with thermoregulation; others increase metabolic activity or interfere with sweating.

Heat illness can happen quickly if people have to work hard in very hot and humid conditions, or are not acclimatized to heat. It can also be cumulative and reveal itself after several days of heat stress wear you down.

Prevention Tips for Heat Illnesses

  • Stay hydrated. Monitor urine output for color and quantity. Snack regularly to avoid hyponatremia.
  • Exercise cautiously in conditions of high heat and humidity. Air temperatures exceeding 90 F (32 C) and humidity levels above 70 percent impair the body's ability to lose heat through radiation and evaporation.
  • Know the warning signs of impending heat illness--dark-colored urine, dizziness, headache, and fatigue.
  • Exercise early or late in the day in hot environments. Rest often.
  • Give yourself and others ten days to two weeks to acclimate.
  • Wear well-ventilated, open-weave clothing. Cover your head and wear sunglasses.
  • The very young and the elderly are less efficient at heat loss, as are people who are very muscular or overweight.
  • Drugs that have been known to contribute to heat illnesses include: alcohol, antidepressants, antihistamines, some anesthetics, cocaine, and amphetamines.