OK, OK, we have a few warm days (like 80 °F). We open all the windows, let the breeze run through the house, and talk about how it’s unbearably hot outside.
Until Labor Day weekend this year.
Then San Francisco had temperatures recorded at higher than 110°F. San Francisco, by and large, does not have air conditioning. San Franciscans do not do well in the heat.
I started to worry as I read about the forecast for temperatures in the 90s. I was scheduled to work the night shifts, and thought it was going to be a few rough overnights. Nothing really prepared me for the environmental mass casualty event of 852,000 dehydrated and overheated people. I realized that San Francisco may be the only major city in the United States that doesn’t have air conditioning for most of its stores and homes. We are perpetually in layered clothing mode, so our frail elderly patients keep their T-shirts, sweaters, and fleece on no matter the temperature outside.
Welcome to heat stroke, dehydration, and elevated creatinine ground zero. I’m told that a normal day gets about 350 911 calls for ambulance services in our fair city. On the worst day of our heat wave, we received 1,400.
I got to work after a quick refresher course from the day-shift doctors where we all agreed to rule out infections while aggressively cooling patients and on how long we would observe them (many went from obtunded to pleasant to cranky within about 90 minutes). Outstanding, overworked nurses swarmed the patients (107 was my highest oral temperature of the weekend) with ice packs, water mist, fans, and cooled IV fluid while simultaneously screening for sepsis. It started out as one of those feel-good, everyone-pitches-in-type shifts, but honestly by hour seven of continuous EMS ring-downs (on top of all the other normal Saturday night patients), we were ready for the hurting to stop.
Have a Plan
We actually admitted very few patients to the hospital, really just the ones with other issues besides heat stroke or heat exhaustion that we would have admitted anyway. The vast majority, even with significant comorbidities and an average age of 87, felt better after fluids and cooling (and the AC of the hospital), and were itching to leave. I thought for sure they would all have elevated lactates with core temperatures of 107°F, but amazingly, if they were “just” heat stroke, their lactic acid levels were under 2 mmol/L.
Several other challenges arose even after the patients were cooled and normothermic. First, how do you discharge these frail elderly patients? Back to their homes? My own second-floor house was 98 degrees, according to our thermostat, and I imagined most of my patients’ homes were the same. Finding a safe disposition so that patients don’t just return the next day with a second heat stroke was a major issue. Thankfully, almost everyone had family helping to come up with a safe plan. Second, I wondered, where was I going to sleep? (A 98-degree house that “cooled” to a balmy 85 at night didn’t seem like a great option.) I’ll admit, I have never slept more soundly than in the hospital call room during the day: ear plugs and air conditioning were all I needed.
The public health response was unfortunately delayed. San Francisco opened its cooling centers (libraries and public pools mostly) a day into the crisis, which certainly helped, but I think culturally San Franciscans really have so little experience with heat that they don’t realize just how dehydrated humans can get (being compliant on your Lasix doesn’t help either).
When an event causing a mass influx of patients happens to your ED, I think the best thing to do is to follow your disaster plan (and if you don’t have a disaster plan, you need one) or at the very least be systematic about your management. It’s easier to have the same plan for all the affected patients than to try to be nuanced in your workups when you can’t miss anything, have competing alternative diagnoses, have to be thorough, and have to act quickly. And call in more ED nurses. They’re worth their weight in gold. Ours are particularly skilled at removing bras, undershirts, T-shirts, long sleeve T-shirts, button-down shirts, sweaters, fleece, and jackets in 20 seconds and replacing them with gowns and ice packs. Thank you, team!
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