MAJ. MEGHAN GALER, M.D.
Martin Army Community Hospital
Fort Benning, Georgia

Exertional heat stroke (EHS), exercise-associated hyponatremia (EAH) and other heat-related illnesses (HRIs) are tragic and largely preventable causes of death and disability at Fort Benning, Georgia, and other hot-climate training areas. This spectrum of illnesses has a significant negative impact on training and poses substantial risk to the medical readiness of trainees and Soldiers.

As an emergency medicine physician at Fort Benning, I see firsthand the devastation these illnesses cause. I studied military medicine at the Uniformed Services University and graduated from a top military residency in emergency medicine. I love caring for Soldiers. Upon completing residency in 2014, I moved to Fort Benning, where I quickly realized that despite my training, I was woefully underprepared to care for the volume and severity of EHS and other HRIs we see here.

For a physician and care team to become adept at caring for patients with a certain type of illness, they need to see a high volume of patients suffering from that illness. The fact of the matter is severe cases of EHS and EAH are actually rare, and a civilian physician may only see a few throughout their entire career. The military population is different, however, and Fort Benning is a world of its own.

Fort Benning is home of the Maneuver Center of Excellence. It is one of the largest training posts in the U.S. Army and responsible for conducting Infantry and Armor Basic Combat Training, Infantry and Armor Basic Officer Leadership Courses, Maneuver Captain's Career Course, Airborne School and Ranger School. Also located at Fort Benning are the 3rd Ranger Battalion, 75th Infantry Regiment and 4th Ranger Training Battalion. Many of these training programs involve intensive outdoor activity. It is this volume of high-intensity training, combined with the high heat and humidity typical of the southeastern U.S., that causes Fort Benning to regularly lead the DoD in the number of HRI cases each year.

This high number of patients is also what has afforded the physicians and care teams at Martin Army Community Hospital (BMACH) the volume of experience required to become exceptionally good at caring for them. Over the years, best practices for prevention and management of these disease processes have been developed in many iterations with varying degrees of success. But institutional memory seems to inevitably fade. This is a predictable result of the regular staffing and command changeovers we all love and hate so much about Army life. Thus, what we have inadvertently established is a recurring pattern of tragic death and a renewed interest in management and prevention, followed by a period of improved performance that subsequently dwindles as personnel come and go until another tragic death occurs. I call this “the tragedy loop,” and we’ve been stuck in it too long.

In 2016, the tragedy loop struck again at Fort Benning and we lost a promising young officer in training. In response, clinicians at BMACH once again became heavily engaged in efforts to provide the best possible guidance and clinical care for HRIs. We developed comprehensive clinical protocols that span from point of injury through disposition (“The Benning Protocols”). Our ambulances are uniquely equipped with point-of-care sodium testing, and our emergency department, to our knowledge, is the first in the DoD to protocolize and regularly employ endovascular cooling for severe EHS. But how could we make our progress sustainable? What could we do differently, this time, to attack the larger problem — the tragedy loop itself?

This was the beginning of the “Heat Center” initiative. The answer seemed obvious, once we thought of it. Torches need someone to carry them. In medicine, this responsibility falls to specialty centers. There are trauma centers, stroke centers, cardiac centers, pediatric centers, etc., and as physicians, we know the best ones by name and look to them for best-practice guidelines. Yet no such paragon exists for HRI because no place else in the world sees a volume of patients sufficient to support such an effort. No place but here.

So, what is it that all of these specialty centers have in common? It isn’t just excellence in management. They also, without exception, focus on prevention and clinical research. Management, prevention, research — this was the “triad” we set out to emulate. By focusing on excellence in these areas, would it be possible to end preventable death and disability from HRI at Fort Benning? Resoundingly, yes.

Since the start of this initiative, we have had zero soldier deaths from HRI at Fort Benning despite several soldiers presenting with core temperatures greater than 109 F! A comparison of our HRI statistics from 2017-2018 clearly demonstrate that our catastrophic cases are down despite total number of cases having increased. We believe this is a clear result of our deliberate three-pronged approach.

As stated, excellence in clinical management alone isn’t sufficient. It has to start with prevention. Our annual Fort Benning Heat Forums are a truly collaborative effort that provide an invaluable opportunity to bring medical and non-medical leaders together to review current guidelines and develop best practices for preventing and managing HRIs. Additionally, BMACH clinicians provide regular outreach to units for refresher training and support. The value of establishing and maintaining an open line of communication between medical and non-medical leaders cannot be overestimated. There are a lot of myths out there regarding how to best prevent/treat EHS and EAH, and establishing a dialogue to dispel those myths and exchange accurate information has proven to be of paramount importance.

Research ties it all together. There are entire teams of brilliant and dedicated researchers out there passionate about this very subject. By bringing together the researchers, clinicians, leaders and our high volume of patients, we can advance medicine. Several large-scale heat stroke studies are already in progress, which will significantly improve military readiness regarding HRI. Additionally, we have begun the process of establishing an Office for Clinical Research Support (OCRS). The OCRS will allow us to better facilitate such partnerships, streamline the administrative requirements and turn Fort Benning into a mecca for heat and other clinical readiness research.

The Heat Center initiative is no longer just about Fort Benning; it’s about establishing BMACH/Fort Benning as the torchbearer, so to speak. Mastering mitigation and management strategies for HRI and becoming a sustainable resource for best practices throughout the DoD will improve readiness and save warfighters. This will pay dividends in establishing and maintaining military superiority in inhospitably hot environments. This is how we end the tragedy loop.


FYI
If you’re interested in supporting the Heat Center initiative, please contact MAJ Meghan Galer at meghan.galer.mil@mail.mil.