Mental Rehearsals: Responding to Heat Emergencies

While temperatures have begun to cool across the country, heat emergencies can still occur. And because heat is the leading cause of death among all hazardous weather conditions in the U.S., OSHA recently published its Notice of Proposed Rulemaking for Heat Injury and Illness Prevention in Outdoor and Indoor Work Settings (see more at www.osha.gov/heat-exposure/rulemaking). Would you know what to do if one of your co-workers collapsed on the job due to heat-related illness?

Let’s say you are working in the right-of-way. It’s a simple pole transfer, but it’s being done out of the hooks. The temperature is already over 90 degrees Fahrenheit and expected to climb close to 100. There are four of you: you and Joe, the climbers, and two other men on the ground. Joe says he is feeling a bit lightheaded as he is pulling up and dead-ending one of the 336 aluminum primary conductors. You notice he is flushed and sweating and has drenched his shirt and pants. You say to Joe, “Hey, we have this outage for most of the day, so let’s climb down and take a break in the shade and get a cold drink.” Joe replies, “What? Did you say take a break?” You confirm and Joe immediately starts to descend without speaking.

When Joe gets to the ground and is stepping off the pole, one of the ground guys notices he is soaking wet; even his leather gloves are soaked through. Joe then wobbles and falls to the ground in a heap, unconscious.

What do you do?

My guess is that you have training in first aid, CPR, bucket rescue and pole-top rescue. But how often have you rehearsed for an event that requires use of that training? Studies have proven mental rehearsal and visualization fire the same neurons in our brain as actual physical practice.

To be effective, mental rehearsal must be specific. In the case of Joe’s collapse, the list of things to be done include the following:

• Assess Joe’s condition and call 911.
• Begin cooling Joe’s body temperature. What will you cool him with and how will you administer it?
• Determine how long it will be before emergency responders arrive. Can the responders get to you in the right-of-way? Be sure to secure the scene for their safety.
• Locate the first-aid kit and AED.

Call 911
Upon calling 911, you will be expected to provide your location and an assessment of Joe. What would your assessment be? Joe is unconscious but breathing, and he is flushed and soaking wet with sweat.

In the field, very few of us are trained to the level of a responding paramedic. Our job is to recognize and appropriately treat Joe while waiting for first responders. In a heat emergency, a change in consciousness must be considered heat stroke until proven otherwise. It’s also important to note that heat stroke is often described as flushed, hot and dry. However, “dry” is unlikely in the case of industrial athletes performing physical tasks outdoors in high temperatures.

In Joe’s case, immediate, aggressive cooling is necessary; that’s because if heat stroke is not treated more aggressively than heat exhaustion, the outcome can be devastating. So, do you have the right supplies on-site to cool him? The American Stroke Association recommends moving Joe into the shade or indoors, removing his excess clothing, and cooling him with water, fans, ice packs or cold, wet towels. (See www.stroke.org/en/professionals/stroke-resource-library/prevention/heat-stroke-vs-stroke for more, including information on the differences between a stroke – which is caused by a blocked or burst blood vessel in the brain – and heat stroke, which is when your body overheats and your core body temperature rises significantly.)

When Will First Responders Arrive?
After Joe’s collapse, you may be tempted to put him in the company pickup truck and rush him to the designated hospital written on your job brief. Don’t do that. The 911 system is designed to bring patients to the closest appropriate hospital – which may not be the one on your job brief. Hospitals and urgent care facilities can also be overwhelmed by patient load due to anything from a pandemic to a bus accident to another multi-casualty event. Always follow the 911 dispatcher’s directions.

In Joe’s case, imagine the dispatcher says, “It will be 15 minutes before help arrives at the intersection of the road and the right-of-way you are in.” Can you meet the responders and quickly bring them to Joe? If more time and equipment are needed to access Joe, are you prepared to continue aggressively cooling him while you wait? Do you have the right supplies? Again, what is your plan?

First Aid and Supplies
Because Joe is unconscious, he can’t protect his airway if he vomits or if secretions move to the back of his throat. Positioning him on his side is warranted to keep his airway clear.

While waiting for first responders, Joe should be assessed regularly to make sure he is still breathing. If he is not, CPR must be started, and an AED should be available for use. Someone will need to stay with Joe at all times and monitor his condition, including his continued cooling. His shirt should be off, and cooling should be applied to his armpits, neck and groin.

You might be wondering, how should we continue to cool Joe with the finite number of cooling aids available on the job site? One option is to move Joe to the cab of a work vehicle and make use of the air-conditioning in addition to cooling him with water, ice packs and the like. Oil spill kits can come in handy, too; some types have spill reservoirs that resemble a kiddie pool. Put Joe in the “kiddie pool” and pour in ice water. Note that you could also dunk an absorbent sock in ice water and apply it around Joe’s neck.

The Cooling-Too-Quickly Myth
Yes, children can develop febrile seizures from changing body temperature too quickly. But for the 14 years I worked at the Ironman tent in Lake Placid, New York, we always had a kiddie pool with ice water in which to submerge adult athletes suspected to be having heat emergencies. That’s because a human being can survive a seizure, but we will not survive if our brain is cooking above 105.8 degrees Fahrenheit. Aggressive cooling is necessary if we suspect heat stroke.

What About the Person Who Says, ‘I’m OK’?
Profuse sweating in high temperatures can create an electrolyte imbalance. Low sodium is a problem called hyponatremia; low potassium is known as hypokalemia. The human heart relies on a balance of sodium and potassium to create the potential necessary to beat properly. When someone has been cooled down from a heat emergency and begins to improve, it is very possible they still have an irregular heartbeat that can cause sudden cardiac arrest. As such, someone recovering from a heat emergency should not be left alone. This is unsafe and can result in their death. Also, someone recovering from a heat emergency may be nauseated and won’t want to eat; they should be encouraged to eat bananas and drink fluids with electrolytes.

Conclusion
The time to prepare for emergencies is before they occur. Doing mental rehearsals to prepare for an event improves outcomes, reduces the stress response during the event and allows us to safely fail. What’s your plan?

About the Author: Bill Martin, CUSP, NRP, RN, DIMM, is the president and CEO of Think Tank Project LLC (www.thinkprojectllc.com). He has held previous roles as a lineman, line supervisor, project manager and safety director.