COMMENTARY

A&E Perspective: Heatwaves in the Emergency Department

Dr Dan O'Carroll

Disclosures

August 16, 2019

"I like it hot. Turn up the heat. I wanna feel the sweat drip from me." So sang rocker Blaze Bayley, briefly the lead-singer of heavy metal giants Iron Maiden

   

Blaze Bayley & Dan O'Caroll (2010)

Most of us living in the rather moist and temperate climate of the UK would tend to agree, but the recent high temperatures have contributed to further challenges to our UK Emergency Departments (ED).

 

Past Summers

I'm old enough to remember when the summer months working in the ED were generally quieter than the always hectic and stretched winter periods. The numbers of patients attending tended to be lower and there was a shift in the reasons for attendance. During the winter months, respiratory presentations were higher, but in the summer months the longer daylight hours and less wet weather meant the amount of trauma being seen increased as children spent more time carrying out outdoor activities and falling out of trees etc.

During the summer months the staff were able to re-charge their batteries and work was generally less stressful and more fun. This has changed for the worse in recent years and shows signs of further deterioration this year. It has disappointed many of us that the hot sunny weather did not bring any respite this year.

Year-round Pressure

In July of this year only two of the 119 EDs that submitted performance data managed to achieve the UK government's 4-hour target. The total number of attendances was more than 2.2 million (the highest ever recorded), with the average number of attendances per day reaching over 73,000. Major EDs (Type 1) had more than 1.4 million attendances, which is an increase of 3.7% compared with July 2018.

The only real difference between winter and summer working in the UK EDs is that environment temperature, and subsequently tempers, seem to have raised as the air conditioning is either absent or overwhelmed by the crowded departments. Although reassuringly in anticipation of winter, I was 'pleased' to see that the radiators in the consultant office appear to have come to life, having been noticeably off during the winter months!

Increasingly frequent extremes of temperature are a result of climate change, and perhaps those of us working in health care and those involved in public health need to make ourselves more familiar with the potentially serious implications of extreme heat.

Record Temperatures

This summer has seen the hottest month globally since records began. Europe has experienced many record high temperatures and there have been many reported heat related deaths, including those of two cyclists. Southern France experienced temperatures of 45.9C, which is comparable to California's Death Valley. One of the deaths occurred during a race in the Pyrenees, which was called off after several participants were taken ill.

The EDs in the UK are more used to dealing with 'low-level' heat related problems. This usually involves excessive time spent in beer gardens, causing presentations associated with excessive alcohol consumption, with additional complications of dehydration and often sunburn. It often surprises us that adults choose to attend EDs due to the predictable effects of sunburn.

Heat-Related Problems

Heat exhaustion, is not usually serious but unless it is recognised and steps are taken to cool down, it may go on to become heat stroke. In heat exhaustion, a temperature of 38C or above may be a feature as well as headaches, confusion, dizziness, loss of appetite and nausea, cramping of legs, arms, and stomach, as well as excessive sweating and pale clammy skin

Heat stroke happens after prolonged exposure to or physical exertion in high temperatures. It is potentially life-threatening if the core body temperature exceeds 40 C. The clinical features of heat stroke also include altered mental state; nausea and vomiting, tachypnoea, tachycardia, and headache. The loss of autoregulation causes organ damage, and organs including the brain may swell, causing permanent damage or death.

Heat stroke can be prevented by simple measures including wearing appropriate clothing, application of sun cream to prevent sunburn, maintaining adequate hydration, acclimatisation, and siestas [in the hottest part of the day]!

Medical treatment of heat stroke usually involves cooling methods including cold water immersion, ice packs in pertinent areas (eg, axilla and groin) and possibly medications such as benzodiazepines to reduce the heat produced by muscles that are shivering.

Heat Warnings

Although many European countries issued health warnings due to the abnormally high temperatures, anecdotally, this year, we didn't seem to have an increase in obvious heat related illnesses in the UK. Studies from the prolonged European heatwave in 2003 reported that the number of deaths in those over 75 years of age was 21.3% higher than 2002. A review article went on to hypothesise the reasons for this.

Older people, in particular, seem to be vulnerable to heatwaves and this is due to heat aggravating underlying cardiovascular and respiratory conditions along with impaired ability to dissipate and regulate core body temperature. Older individuals also have a reduced response to thirst and can experience greater levels of dehydration, which can be further exacerbated by their medications. Built up areas with high densities of buildings experience higher temperatures, but air conditioning is thought to lessen the risks of heat related illnesses. This means that in some countries, low economic status is also a contributing factor.

It seems that since the 2003 heatwave, the introduction of heat alert systems as well as heat management strategies can reduce heat related mortality, as there was a reduction relative to prior events during the heatwave of 2013 in England. It is worth nothing that acclimatisation to heat is apparently protective to extreme hot weather, which means the population in the UK could be more susceptible to extreme heat as we're very much not used to it! Failure to respect high temperatures can result in tragic consequences for young individuals exerting themselves to the point of exhaustion or even death.

With all of that in mind, it's time for me to ignore all of the sensible advice and I'm off to Spain, planning to re-enact Ray Winstone's opening scene in the movie Sexy Beast .

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