Collapsed Sepoy After a Loaded March
A 24-year-old sepoy collapses at the end of a 5 km loaded march in 34°C heat and 80% humidity. He is confused and aggressive and says he has cramp. His skin is hot and dry, pulse 132, respiratory rate 28, systolic blood pressure 100 mmHg. He drank 500 ml of water 40 minutes ago and has not urinated for six hours. His section has one medical orderly, a first-aid pouch with oral rehydration salts, no ice, and a vehicle 12 minutes away. The nearest medical officer is 45 minutes by road. The patient refuses to lie down and tries to walk back to the lines.
1. What is the most likely diagnosis, and which findings push you to it rather than to heat exhaustion?
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The working diagnosis is exertional heat stroke, not heat exhaustion. The decisive findings are altered mental status, confusion and aggression, combined with hot dry skin, pulse 132, respiratory rate 28, and low systolic pressure after heavy exertion in 34°C and 80% humidity. Heat exhaustion usually leaves the patient lucid and sweating; this patient is not safe to send to the lines to sleep it off. The lack of urination and poor fluid intake add to the risk, but oral fluids are not the priority. A core temperature should be measured if a thermometer is available, but cooling must not wait for it. Treat every confused, hot patient after exertion as heat stroke until proved otherwise.
2. List your first five actions in order, with the reason for each.
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First, move him to shade, remove excess clothing, and cool him aggressively with water and fanning; apply ice packs to the neck, armpits, and groin if any are found. Second, call CASEVAC immediately, giving the grid, the patient's condition, and the treatment started. Third, protect the airway and do not give oral fluids because he is confused and may aspirate. Fourth, monitor breathing, pulse, and consciousness and be ready to place him in the recovery position. Fifth, do not let him walk; use two men to guide or carry him to the vehicle and continue cooling on the way. The 45-minute road time makes immediate cooling and early evacuation parallel actions, not sequential ones. Do not use salt tablets or antipyretics as a substitute for cooling.
3. How should the section handle the patient's refusal to lie down and the long evacuation time?
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The patient's refusal is a symptom, not a valid decision. Two soldiers should guide him firmly to the shade without arguing, and the medical orderly should keep giving simple, calm instructions. He should not be allowed to walk back to the lines, because exertion worsens heat stroke and he may collapse. Cooling should continue while the vehicle is moving, with wet cloths and fanning, and someone should stay with him at all times. The radio message should state the grid, the suspected heat stroke, the cooling already done, and the request for urgent evacuation. The section commander should also warn the receiving medical officer that the patient is confused, so the handover is not delayed. Restraint should be the minimum needed to keep him safe and should be released as soon as he cooperates.