Heatstroke Lesson Sharing from the Nez Perce-Clearwater National Forests

[This blog post enlightens you to how we might best reflect and learn from the experience of others—avoiding the “Us and Them” pitfalls. It also shares vital information about concepts and practices that might be new to you—including “capacity sponges” and the “TACO” method for saving someone’s life. Pertinent topics here include “Three Dangerous Myths About Heatstroke” as well as lessons for heatstroke treatment in the field.]

by

Brett Rogers, Safety Manager, Nez Perce-Clearwater National Forests

Jon Moore, Fire Operations Specialist, Nez Perce-Clearwater National Forests

“Any Ole Fire” U.S.A.

Standing in morning briefing listening to the weather forecast, you can’t help but wonder about the expected high temperatures and thunderstorms predicted for the day. The meadow where base camp is located is soaked with dew each morning and you heard that firefighters awoke to frost one morning a week earlier. But you know this is not unusual. Cool (even cold) conditions in the morning followed by blazing hot conditions in the afternoon are not unheard of. This, after all, is how it goes in wildland fire. You encounter all kinds of conditions, all kinds of extremes in all kinds of country. Wildland fire is not your Groundhog Day type of 9-to-5 job. While it can be monotonous, there are plenty of exciting times to keep things interesting. And that is why you love it.

Your assignment for today’s shift is to continue to hold and secure a road that is being used as a control line. One side of the road has been completely cleared of trees. This was done a few years earlier, making a fuel break that was built as part of containment efforts for a large fire that had occurred in the same area. As long as the fire didn’t spot all the way across the road and the fuel break, this should be a good place to halt the progression of the current fire. Besides, there really were not many other great options. The fuel break was the only such break in a sea of mixed conifer and lodgepole that was chock full of snags. The previous fire had broken-up some of that continuity, but there was still plenty of green to be concerned about with this fire.

Later that afternoon, as temperatures climbed and relative humidity fell, winds which had been calm that morning, became gusty and erratic. Atmospheric instability has now paved the way for thunderstorm development. All of this came together permitting the fire to flare-up and spot across the line/fuel break, followed by a slop-over that would grow rapidly.  

Now you are shifting gears from securing and holding, to trying to contain a slop-over. Air Attack is up and the air show commences in support of the ground effort, working to contain the escape. Retardant and bucket drops of water are working to slow down the fire ahead, as you and your crew anchor in and begin building fireline along one flank of the slop-over.  

Things are going pretty well. The crew is engaged and constructing some respectable fireline. There is quite a bit of saw work so progress would be slow, but you were making progress, nonetheless. Life is good.

You bump-up the line to check on the sawyers and find they are doing well. It is hot and sweaty work, but they are doing fine. After briefly talking with them you continue ahead to scout line location. You are only gone for a few minutes and return to the saw’s location. One of the sawyers now doesn’t look so good. They are acting a little rummy. Talking to them you realize that they are experiencing heat illness and need some help.  

All of a sudden, the sawyer who is overheated collapses and is not responding to verbal stimuli. This is now an emergency! You call in a RED Priority 1 Transport for Life-Threatening Injury or Illness. You receive word that the Line Medic assigned to the fire is on their way to your location and that Life Flight has been ordered. It would also be more than half-an-hour before the Line Medic arrives on-scene.

You receive word that Life Flight is more than one hour out. Hearing that news, the call is made to have the helicopter, that is doing bucket-work, reconfigure for a medivac to expedite getting the firefighter to definitive care. You begin to move the firefighter toward the medivac site, where you also intend on meeting the Line Medic. You also know that there is a creek near the medivac site that you can use to help cool the firefighter down. Things are happening fast, but it sure feels like things are taking forever!

Opportunities for Organizational Learning

You may be wondering why the story of this Lessons Sharing is written in this particular manner. And some of you may be angry that it is written in such a way! Under your breath you might be asking:

• Where are the specifics?
• Where is the timeline?
• Where were mistakes made?
• What could they do better next time?
• What went well? (And, by the way, a whole lot of things were done very well.)

Well, we did so because of the Us and Them model which we all use when hearing about events that happen to others.

Truth is there was nothing abnormal about the work the firefighters were doing, nor the conditions in which they were operating. We (us), have all been there before. Doing normal work when something we didn’t want to occur, occurred. And we (us) like them (also us) do extortionary things in the face of uncertainty and chaos to create positive outcomes when things get complicated by unwanted or unanticipated events.

In many ways, this story is just a story and nothing more. It is a recollection of how events were perceived by those involved, and sadly and more sinisterly, often a recollection by those not involved. Going backwards and picking out specific points in retrospect probably is not very productive. Especially if you were not the person at the pointy end of the stick. For the person looking back in retrospect, it creates the illusion of having a better understanding of the situation than the persons involved actually had at the time. Why? Well, because you know the outcome! That is something that the persons going through the event did not have the ability to know at the time, or they would have most likely created a different outcome.  

A better way to reflect on this story might be to place yourself in the story/scenario and ask:

• What do we have in-place in our operations/system to deal with similar events, and is this enough?
• Does our operation/system rely on perfect human performance?
• Where are the areas that we can add capacity to deal with undesirable events?  
• What are some things we can do regardless of what level of the organization/operation we are in?

A friend of ours humorously refers to these things as capacity sponges. Capacity sponges being things that you can do or add to increase your capacity to absorb unanticipated or unwanted events. We love this metaphor in that it takes into consideration that there truly are not any bomb-proof safeguards in wildland fire operations. But by adding capacity sponges, we can certainly help manage toward better outcomes when the proverbial poo hits the fan.  

Additional Information

Classic vs. Exertional Heatstroke

Often when we think about heatstroke, we tend to think about it in relation to the heatstroke we learned about in basic first aid classes or what we see on the news during a heat wave. Classic heatstroke typically occurs in the elderly or very young and is attributed to the body not being able to adequately cool itself during excessive environmental heat (such as heatwaves). Classic heatstroke generally develops slowly.

Exertional heatstroke on the other hand is attributed to the body not being able to cool itself adequately during activities, such as athletics, or arduous manual labor. Excessive environmental heat may be present, but it is also the body’s generation of heat that is part of the problem. Exertional heatstroke develops rapidly.

Exertional Heatstroke Symptoms

Exertional heatstroke occurs when the core body temperature rises above 104°F (hyperthermia).

Signs of heatstroke can initially be similar to heat exhaustion and may also include:

• Clumsiness
• Slurred Speech
• Stumbling
• Confusion
• Rapid Pulse
• Rapid Breathing (Hyperventilation).

The skin may be wet or dry at the time of initial collapse, but as it advances, sweaty cool skin is a common sign of heatstroke.

Heatstroke can progress to a dangerous level in just 10 to 15 minutes.

Aggressive cooling is the most critical factor in the treatment of exertional heatstroke. Immediate measures must be taken—an ice water bath may be the quickest way to cool the person down, but perhaps not the most practical in the field. Alternatives would include using ice packs or ice water-soaked towels—at least in the armpits, groin, and neck. (For TACO Method see: “Heatstroke Treatment in the Field” below.)

Although some patients exhibit a misleading lucid interval that often delays the diagnosis, observation and cooling therapy should continue. It is critical to keep cooling measures going until professional medical attention is attained.

Three Dangerous Myths about Heatstroke

Myth 1: Victims don’t sweat.

You may hear this myth stated like this: You can tell the difference between heat exhaustion and heatstroke when the person stops sweating. There is some truth to this. A person who has become so dehydrated and overheated that they lose their ability to sweat IS more than likely to experience heatstroke. However, just because a person is still sweating doesn’t necessarily mean they aren’t experiencing heatstroke. Exertional heatstroke, in which the person is engaged in strenuous activity, may occur even if the person is still sweating, often excessively.

Myth 2: An ice bath or ice water may cause the person to go into shock.

It makes sense. The body needs to regulate its temperature within a narrow range and dealing with the extreme cold and heat at the same time may send it into—shock? Except this isn’t even really a half-truth. There’s little-to-no evidence that the body will go into shock or that the dangers of cold-water immersion in any way outweigh the potentially life-saving benefit. Multiple studies have concluded that cold-water immersion including ice baths are an effective treatment or even the gold standard for heatstroke and hyperthermia. The life-saving fact to recognize is that time is of the essence. This is why the best advice is to cool the person down using whatever means are available.

Myth 3: They just need to drink more fluids.

This myth, too, is only a half-truth, since, yes, dehydration can be a factor. But it may also just be a result of the body trying to cool itself. A person who is engaged in activities involving a high level of exertion can be hydrated and still experience heatstroke if the environment or situation is such that perspiration is not enough to cool the body. Clothing, air temperature, humidity, radiant heat, and wind also play a role in how effectively the body can cool itself. Similarly, physical fitness and acclimation are important factors in one’s ability to work in the heat.

Think about the world class athlete that goes down with heatstroke. They are in great shape, have access to the best support in the world, but when pushing hard their body can’t cool itself. Nature always wins. 

While hydration is very important to helping fend off heat illness, simply drinking enough water will not always prevent it. You need to consider the workload and environmental factors as well. The blog post: Heat Stress: It’s Not Just about Drinking Water by the National Technology and Development Program (NTDP), talks about one important factor that we tend to overlook—pack weight: The average total pack weight carried is 39 lbs. However, this is just the average pack weight, which does not account for the weight of other equipment such as fuel, tools, chainsaws, etc.

Heatstroke Treatment in the Field

How do you treat for heatstroke in the field? We know that it is an immediately life-threatening condition so getting the patient to definitive medical care as soon as possible is definitely in the mix. Heatstroke is going to be a (RED) priority transport. However, with heatstroke rapid cooling is definitive care and should be initiated prior to transport. Given that we are often barely within the “Golden Hour” of transport time to advanced medical care for traumatic life-threatening injury, initiating rapid cooling before transport is crucial to the survival of heatstroke victims.  

So, what does rapid or aggressive cooling look like? Many of us learned in first aid training that we can remove some of the victims clothing and place icepacks in the major body junctional areas/arterial areas (groin, armpits, neck). Splash water on them, move them to the shade, etc.? But how effective are these methods at really rapidly cooling the heatstroke victim? Remember, time is of the essence.

Are there other potential methods we could use to rapidly cool our heatstroke inflicted patient? A couple ideas we could look into might be:

1. Line Medics are provided a cooler that is filled with ice and wet towels that can be used to help cool victims with a bit more efficacy than the chemical icepacks in first aid kits or trauma kits. This could be helpful to treat lesser forms of heat injury/illness in the field as well.
2. Another possibility is utilization of the Tarp Assisted Cooling with Oscillation (TACO) method to aid with rapid cooling of patients with suspected heatstroke. Utilizing a poly tarp to place the patient on, followed by 5 to 20 gallons of water (with ice if possible), then rocking the patient back-and-forth to circulate the cool/cold water around their body to facilitate rapid cooling.

Would it be possible to utilize a fire-shelter for the TACO method? Or emergency/space blanket? With some good old-fashioned ingenuity, firefighters of course could find creative and innovative ways to add capacity sponges to their operations to help them manage heatstroke incidents. Even identifying and reminding others that places such as streams or fold-a-tanks as locations to rapidly cool patients, could be helpful.

Additional Resources

Heat Illness Basics for Wildland Firefighters, Fire Tech Tips, Technology & Development Program United States Department of Agriculture Forest Service June 2011, Joe Domitrovich and Brian Sharkey.

Two-More-Chains: Us and Them, Summer, 2015, Alex Viktora– Wildland Fire Lessons Learned Center.

Heat Stress: It’s Not Just about Drinking Water, June 12, 2020 – Wildland Fire Lessons Learned, The National Technology Development Program (NTDP)

The Ins and Outs of Hydration, July 21, 2020 – Wildland Fire Lessons Learned, The National Technology Development Program (NTDP)

Heat Illness and the Wildland Firefighter Risks, Research, and Recommendations, Research Report for: Bureau of Indian Affairs October 14, 2011, Crista Vesel.

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Heat Illness: 2019 Update, Wilderness Medical Society Clinical Practice Guidelines | Volume 30, ISSUE 4, SUPPLEMENT, S33-S46, December 01, 2019

Cooling Effectiveness of a Modified Cold-Water Immersion Method After Exercise-Induced Hyperthermia, Journal of Athletic Training, 2016 Nov.

Consensus Statement- Prehospital Care of Exertional Heat Stroke, Prehospital Emergency Care, 2018

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