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People often neglect to take precautions for extreme temperatures, such as going outside in inappropriate clothing. Children, older adults, and those with chronic illnesses are particularly vulnerable. Lack of nutrition and hydration can worsen the effects of hot or cold weather. Alcohol impairs the body's ability to regulate temperature. Humidity and wind also play a role in temperature-related injuries. Cold exposure can lead to localized or generalized hypothermia, with extremities being most susceptible. Proper clothing and protection can help prevent heat loss. The body can modify heat loss through increasing or decreasing heat production, changing environment, and wearing appropriate clothing. There's a tendency not to take precautions for their exposure, right? So they don't... Like my oldest son, when he went to college, he went to college at Colby-Sawyer up in northern New Hampshire in the mountains of New Hampshire. And it was... In the wintertime, it was like negative all the time. And he'd go outside in t-shirt shorts and flip-flops to class. So I mean, he wasn't a child, but people don't... Children don't take the precautions. They don't realize it. They're all playing. They don't realize the temperatures and things. Older people. Older people don't have the physiological reserves to deal with that. People with chronic illnesses, people with like COPD, diabetes, cardiac issues, obese patients, and young adults who overexert themselves. We see this a lot in April. You've got a couple of those warm days in April. It's like 70 degrees. I'm going to go out for a run. I haven't been running all winter, but I'm going to go out for that run. And they overexert themselves. They're not used to it. They have to acclimatize to the temperatures. Environmental emergencies include heat and cold-related emergencies, water emergencies, pressure-related emergencies, injuries caused by lightning. Anybody ever been struck by lightning? Trust me. Nice one. And it was an indirect strike. We'll talk about that. And envenomation, which we already talked about. So physical conditions. Patients who are ill or poor physical conditions will not tolerate extremes of temperature well. Whenever we see people die from, you know, very cold or very extremes like heat waves or really cold spells, people that die, it's generally the elderly. Many times it's the homeless or people that are exposed to these elements. Infants, children, older adults are more likely to experience temperature-related illnesses. Infants don't thermoregulate well. They don't shiver because they don't have the musculature for it. And they don't have a lot of adipose tissue, a lot of insulation. So they succumb to the hots and colds more easily. Children don't know. They don't have the mental wherewithal to get out of that environment. They'll continue to play even though it's 100 degrees below. And older adults don't have the physiological reserves that will allow them to compensate for those temperatures. Nutrition and hydration. Lack of food or water will aggravate hot or cold stresses. Food is energy and energy is warmth. When I was in the Army and when I did my military training and specific different types of training, I can remember that they would let you eat whatever you wanted. They would stack pancakes and bacon on your breakfasts. I remember we used to eat loads of food. You'd have five minutes to eat but you could eat as much as you wanted because that food was energy and energy is warmth. People that don't eat right, don't have proper nutrition, again, i.e. your homeless people or elderly people who might be on fixed income may not have the right nutrition and or hydration. Alcohol will change the body's ability to thermoregulate. Alcohol will actually subject you more quickly to hot and cold related injuries but you won't notice it because it dulls your senses. I've seen a lot of people, you know, oh my God, it's beautiful. It'd be like 20 below zero and they'll go up with a t-shirt. This is beautiful. This is great. Hey, give me another beer. Right? People don't realize how cold it is and that's why alcohol is usually involved in many environmental emergencies. Ninety percent of water related accidents and fatalities have an alcohol or drug component. Here, hold my beer. Watch this. Environmental conditions, conditions that can complicate environmental situations, things like the air temperature, humidity and wind. So the air temperature is important but humidity and wind are more important. Humidity is the amount of moisture that's in the air and this has to do more with hot than cold but in a hot environment, if you have a humidity greater, the human body is anywhere between 68-72% water. If you're in an environment that's greater than 72% humidity, your body thermoregulates. You bring hot blood to the surface. You evaporate the sweat and the cooled blood goes back into your core. That's how you cool yourself. You guys are all sweating right now but you don't even notice that your body is dry because you're thermoregulating properly. So if it's at 72% humidity or greater, my body does not evaporate that sweat because the moisture constantly stays there. So instead of the sweat evaporating and cooling the blood, the sweat, that moisture stays on my skin and gets hot. Now I've got hot, sweaty skin and I don't thermoregulate or cool. So that can have a factor. Also wind, not so much for hot temperatures but now we're looking at the other extreme, the cold, because we talk about wind chills. Wind chills can actually make a cold temperature far worse. If you're driving, it's 40 degrees but you're doing, you put, if you're driving 70 degrees, 70 miles an hour in your car and you put your hand out in 40 degree air, it's actually equivalent to about 10. I had a, I was out, I bought a motorcycle years and years ago when I first bought my Harley V-Rod and I bought it in January and I just, I wanted to ride it. I had to, I bought it, I had to ride it. It was like 19 degrees. And so I tried to drop off as warm as I could and I went on to that motorcycle in January and, you know, I took it out on the highway and then I got back in and literally it took me, this was like 8 o'clock when I went out. I got back about 8.30 and it wasn't, I didn't warm up all night. It wasn't until the next morning that I felt better. I was hypothermic. Afterwards I looked at it, 70 miles an hour at 19 degrees is equivalent to like 30 below. So it was like standing in 30 below temperatures for an hour. Well that was me when I, when I put the truck a couple years ago too. I would sign like, put floss in a t-shirt and for like half an hour. Yeah, that's not good. In the middle of December. I remember extremes in temperature and humidity are not needed to produce injury. It's not the, it's not the negative 10 and the 110 that cause most of the deaths. It's the moderate temperatures. It's 40 to 50 degrees. But being exposed for long periods of time like homeless. And like 80 degrees but 70% humidity. That's where you're going to find the most of injuries because when it's extremes, people tend to be more careful and take more precautions. Like when it's 40 and 50 degrees, nobody thinks about that. Boy, that's beautiful today. I don't even, I just got to wear a t-shirt. It's beautiful out, right? Or if it's 80 degrees with 70% humidity. Oh, it's not too bad. It's only 80 without thinking about it. That's where most of the extremes happen. So cold exposure can cause injuries to the feet, hands, ears, nose, or the whole body. Which is generalized hypothermia. So you can have a localized cold weather injury or you can have a whole body injury, which is what we call hypothermia. Localized, most commonly hit the feet, the hands, the ears, and the nose, the cheeks. The parts of the body that are more exposed with less blood flow. That's where you get most of the injuries. That's why, believe it or not, I always in my jacket, my winter jacket, when I'm working the road, I always have a hat, nice warm hat, and a pair of gloves. And I wear nice boots and socks. 40% of the body's energy is lost through the hands, feet, and head. Good hat, good gloves, good boots and socks will keep 40% of your temperature. So always have that available. Believe it, we can stand around outside for long periods of time waiting to do something. So cold exposure, there are five ways the body can lose heat. So I like to use the example of my son playing football. My son was a big football star in North Alboro. And I used to go watch all the games. And so sitting in the bleachers in a football field, I experienced all five ways to lose body temperature. First of all, conduction. I take my warm butt and I sit on the cold aluminum seat. Heat travels to cold. So my body literally, the heat leaves my body and goes into the aluminum. I conduct heat away from me. Convection, the wind blowing through that hundred yard open field blows right up on me and literally takes my heat off of my body. It blows called convection. You can cook with a convection oven. A convection oven cooks 30% faster than a regular oven. And it doesn't use microwaves. What it does is it takes the heat and blows it with a fan around the food. And it cooks 30% faster because it conducts the heat through the food. So, convection. Evaporation. You are just losing temperature, right? You're losing heat because your body is evaporating sweat. Wet skin cools 20 times faster than dry skin. So you're sweating, you're evaporating that sweat, and you're cooling internally. Radiation. Just your heat leaving your body. It's like a hot shower and go walk out in the cold in the morning. And you can see the heat coming off and the waves coming off of you. It's just radiating body heat. It's just leaving you. And respiration. I breathe in 20 degree air and I breathe out 98.6, right? If my body isn't able to maintain my temperature, how quickly is that going to internally cool me? Pretty quickly. So the rate and amount of heat loss obtained by the body can be modified in three ways. What are those ways? Increase or decrease heat production. Either be more active or less active. What do we do when we get cold? We shiver, right? We shiver. All of our muscles shake at once. They vibrate. And that produces massive amounts of heat. Two best things you can do to maintain body temperature is shiver and stomp your feet. This produces a lot of heat, right? Move to an area where heat loss is decreased or increased. Get into the sun. Get out of the sun. Wear appropriate clothing. Wear layers. Dress in layers. Because it's not about you. It's about your body, your patient. You could be in 70 degree temperature and your patient could be hypothermic. Which means you've got to get them in the ambulance to turn the heat on high. But you'll sweat like a pig because at 70 degrees you're active. You're not cold. You're hot. You're already sweating. It's not about you. It's about the patient. In the wintertime, wear layers because you're going to bulk up when you're outside. But once you get the patient in the ambulance, you can take your layers off so you can work with the patient. So wear layers. Hypothermia. This is systemic. This isn't localized. When the core temperature drops below 95 degrees, body loses the ability to regulate its temperature and generate body heat. Eventually key organs such as the heart begin to slow and mental status deteriorates. The body, your cells in your body, all 50 trillion cells in your body, function at an optimum temperature of about 98 to 99 degrees. 98.6 is average. They don't like cold temperatures. Once you start getting it down to 95 and below, cellular respiration begins to slow to a point where you get to about 80 degrees. Cellular respiration practically ceases. Your cells go into a stasis period. They just stop functioning. They don't burn oxygen. They don't produce energy. They just kind of sit there. That's one of the reasons why they think long distance space travel is possible because we can put patients in a hypothermic state. They don't need oxygen. They're not going to produce waste. They don't need food. Six months. Just stay in a hypothermic state. And it doesn't take zero. They don't have to freeze the body solid like they do in the movies. All they have to do is bring the body temperature to 80 degrees. Internal body temperature. All cellular respiration ceases. They do that for surgery. It's called therapeutic or surgical hypothermia. They can take your body and drop your body temperature to about 85 degrees. They do it when they have to do arterial repair, like your aortic repair, like an aortic aneurysm. They bring your body temperature down. Cellular respiration almost ceases. Then they put you on a heart-lung machine and they bypass your heart, your blood through this machine, which gives you oxygenation. So that oxygenation plus the reduced cellular activity, your body can stay like that while they do the surgical repair. And then they slowly bring your body temperature up again. Is that a hyperbaric chamber? No, hyperbaric chamber is pressurized oxygen. That's different. Hyperthermic hyperbaric is different. Hyperbaric, think of a barrel. Think of a barrel. So it can lead to death. Hypothermia will lead to death if it's not properly treated. Air temperature does not have to be below freezing for it to occur. It can develop quickly or gradually. A partner of mine, when I owned my EMS school, we were partners together, he and his wife and me. And he used to tell a story one time of how he used to like to go diving. And so it was April day, 80 degrees. So he decided to go down to Cape and go snorkeling. And he had a black Volvo with a black interior. So you can imagine a black Volvo, black interior in the bright sunshine, even in April. It's going to get warmer than that. Right? If you think about it. So he decided to go swimming. Well, the water temperature was about 60. But he had what he thought was a good wetsuit. The water was cold. But he went and swam. He swam too long. He noticed he started getting confused. He started getting lethargic. He said there's something wrong with me. So he went in his car. It was very cold at that point. Started his car, turned his heat on high. And he sat in his car for 30 minutes. Direct sunlight in a black car interior with his heat on high for 30 minutes before he started feeling warm again. Now, if we were in that car, we would have been like, I'm dying. Right? It's because he was so hypothermic. Once your body gets cold, it takes a long time to warm up. I had a patient one time. We had a homeless guy. We were in Framingham. We had a homeless guy we brought to Framingham Union, Metro West Framingham. And the body temperature of this patient was 88 degrees. So they did a bunch of things. They put him in the bear hugger. Bear hugger is a blanket that goes over and under the patient. And they pump 105 to 110 degree air in it. And it heats the patient. They also gave him warm IV fluid of about 105 degrees. They gave him gastric lavage. They pumped 105 degree water in his stomach and pumped it out. They constantly had warm water flowing through him. And they gave him warm, humidified oxygen. I went back two hours later with another patient and checked in on him. He was only at 90. So in two hours, he had only gone up two degrees. So hypothermic patients sometimes take a long time to warm up. So people at risk. Homeless people are those whose homes lack heat. You know, you've got the elderly patients. I'm on a fixed income. I need my medication to live. I've got to eat. And I need my rent. What can go? Well, I just won't buy oil. Or I won't turn on my heat. And I can wrap up in blankets. I've gone to homes where, like, in the morning, it's like 20. But in the afternoon, it's 50. We all know that. We live in New England. It's the only place in the world where you have to turn the heat on in the morning, the air conditioning in the afternoon, and the heat at night. So it's 20 in the morning. It's 50 in the afternoon. So you're walking in with just a T-shirt on. You open the door to the house, and you breathe out, and you can see your breath. Because the house is 20 degrees colder than it is outside. And you see this woman all wrapped up in, like, three blankets and a coat. Right? Because that's the way they live. And that's the way people, that's how people die. We find a lot of patients succumb to environmental emergencies in their home. Swimmers and geriatric, pediatric, and ill individuals. Signs and symptoms become more severe as core temperature falls. We have four stages, basically. So mild hypertension, mild hypotension, or hypothermia, is from 95 to 93 degrees. Foot shivering, foot stamping. Do you ever talk to somebody who's really cold? Hey, how you doing today? I'm doing good. I'm just cold. Right? They don't want to talk. They're withdrawn. Leave me alone. Right? I'm cold. Constricted blood vessels. Constricted blood vessels. You'll find that the skin will be pale as the body shunts blood to the core. If it's really cold, you'll get what they call mottling. You'll look at the skin. It'll be blotchy. Blood is actually trapped in the capillary beds because they closed off so quickly to shunt that warm blood to the core. 92 to 89 degrees. Loss of coordination or muscle stiffness. We call this the hypothermic shuffle. They look like Frankenstein. In the wintertime, and it's a terrible thing to say, but look at the homeless. If you're driving through winter, look at the homeless. You see they walk like this. What happens is the nerves don't function when they get below, you know, 92 degrees, and they can't bend their arms. They don't bend their legs. And it's really called the hypothermic shuffle. Slow respirations, confused, lethargy, and sleepy. Sometimes we find patients, we'll find, we'll be looking for patients in the woods, and we'll find a trail of clothing and a person frozen in a snowbank in their underwear. Because they get so confused that their mind thinks they're actually hot. They start taking their clothes off. They're not. They're severely hypothermic. And they end up dying, freezing to death. Severe temperatures, 88 to 80. Coma, weak pucks, dysrhythmias, very slow respirations. When you check a cold patient's blood pressure, you check a pulse, you check for a full minute. You might only get two beats, but you want to make sure you check for a full minute. We don't just say, okay, you know, 30 seconds, times two, no pulse. In hypothermic patients, you can do CPR. You can put them on the AED. They may not respond, but cardiac arrest is cardiac arrest. If you don't feel a pulse, then you work them. And there's a rule in EMS, there's a rule in medicine. You're never dead unless you're warm and dead. A cold patient is not considered dead until they're warmed up. And I don't mean like you walk into a house at 70 degrees and the patient's body temperature is 70. That's different. That's different. I'm talking about from outside, being in the elements. Less than 80 is apparent death, cardiac arrest, and unresponsive. Although we don't say that they're dead because they possibly could survive. We're going to talk about water-related emergencies, but water and cold kind of go together. The longest surviving person underneath the water was 66 minutes. This happened in the late 70s. This 18-year-old drove off a road and into a lake, sunk to the bottom of the lake or on a bridge. And so they got there. It took them 66 minutes to get this guy out of the water. And so the two paramedics said, well, we're not giving up on him. Never dead until you're warm and dead. They worked him. That patient came back with no neurological deficits after 66 minutes under the water. He was so cold, his body shut down. He produced no waste products. He burned no oxygen. The next one is local. There was a girl local in Massachusetts who fell in a pool. And she ended up underneath the pool cover. And it was 60 minutes before they got her and brought her out. They worked her. No neurological deficits. She became a nurse. She worked in Boston. She just recently was in the last few years retired. So there is a potential. That's why we don't say you're never dead until you're warm and dead. We don't give up on them when they're cold. To assess a patient's temperature, you want to get a core temperature. The best way to do it is insert three inches into a body cavity. That's why we go in the ear, under the tongue, or in the rectum. The best temperature to get is a rectal temperature. So if you have the thermometer, knock yourself out and use it. It's important to know. How do you tell the difference between an oral and rectal thermometer? One taste test. I almost broke up when I said that. I said it's the taste. And we don't carry thermometers in the ambulance. I mean, we don't do that. So how do we test? Pull the shirt up. Take the back of your ungloved hand and put it on the abdomen. This should always be warm. No matter how cold you are, this should be warm. If I put my hands here and it's cold, you're cold. It doesn't matter what temperature. Cold is cold. Hypothermic is hypothermic with regards to what we see. Mild hypothermia occurs when the core temperature is greater than 93 but less than 98. Anything less than 95 is considered hypothermic. Above 95, yeah. The patient is usually alert and shivering. Pulse and respirations are rapid. The skin may appear red, but it also may appear pale or cyanotic. You might even have that blotchy skin. They call it modeling. M-O-T-E-L-I-N-G. Modeling. Moderate hypothermia exists when the core temperature is 86 to 93. Shivering stops. Muscular activity decreases. You get the hypothermic shuffle, the confusion. Severe hypothermia is when the core temperature drops below 86. The patient will become severely lethargic, on the foundation, and even unresponsiveness. They'll stop fighting at this point, which is good, I guess. Clotting temperature less than 80. Pulse is almost non-existent. This cardiac dysrhythmia is one of the important things. If you have a patient who's hypothermic, we don't want them to get overly agitated. We don't want them walking. We don't want them getting excited. We want to keep them calm, pick them up, and carry them out. Because what happens is the heart becomes very irritable when it becomes cold, and patients can develop dysrhythmias. The most common one is ventricular fibrillation. They can go right into V-fib right in front of you. V-fib is cardiac arrest. But we don't want that. So keep the patient calm. Don't let the patient walk. Don't let the patient keep them calm. Never assume that a cold, pulseless patient is dead. Take a break. What's that? What do you mean? Sometimes they do. Sometimes they do. Yep, yep. But in a situation like that, if they're... But the thing is, they're dead. In other words, what they're saying is the patient will appear dead, but they're not. They're hypothermic. If you see something like that, the patient's dead. Yeah. You've got a day break. Take five minutes. Yeah. Yeah. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. 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