Dr. Patrick Fink interviews Dr. Nick Daniel and Dr. Gavin Clark about an in-hospital case of exertional heat stroke in a mid-20s runner who collapsed just before the finish of an October New England half marathon in 45°F weather. EMS treated presumed SVT with adenosine, but in the ED the patient was hypotensive, profoundly diaphoretic, and altered; an oral temperature was normal while a rectal core temperature was 105.5°F, highlighting that peripheral temps can’t rule out heat stroke.
We discuss rapid “cool first” management using ice packs, misting, and fans to reach 102°F within ~30 minutes, compare cooling methods (cold-water immersion, tarp-assisted oscillation, Quantico method, frozen sheets), review labs showing lactate 9 and AKI, explain sepsis-like physiology via gut hypoperfusion, and note possible risk contribution from recent COVID and acute Lyme IgM positivity.
Links:
Ep. 33 - Heat Illness Fundamentals
Ep. 27 - Thermoregulation: The Physics and Physiology of Body Temperature Regulation
Clark G, Kocen S, Daniel N. Icy Hot: A Case of Unexpected Heat Illness. Wilderness Environ Med. 2026 Jun 16:10806032261458332. doi: 10.1177/10806032261458332. Epub ahead of print. PMID: 42300334.
Eifling KP, Gaudio FG, Dumke C, et al. Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Heat Illness: 2024 Update. Wilderness & Environmental Medicine. 2024;35(1_suppl):112S-127S. doi:10.1177/10806032241227924
Chapters:
00:00 Show Intro and Guests
02:43 Meet the Doctors
03:48 Race Day Collapse Setup
04:47 Finish Line Differential
06:48 EMS Report and History
08:55 Core Temp Surprise
11:25 Field Temp Takeaways
13:38 Rapid Cooling in ED
15:36 Cooling Rates and Goals
16:28 Immersion and Alternatives
18:17 Tarp and Body Bag Hacks
19:32 Quantico and Frozen Sheets
21:10 Field Cooling Methods
21:48 Lab Workup Red Flags
23:23 Lactate Nine Explained
24:21 Heatstroke Sepsis Pathway
26:40 Hidden Factors COVID Ticks
29:09 Fever Versus Hyperthermia
31:27 Prehospital Takeaways
35:00 Race Day Kit Checklist
36:35 Cool First Transport Later
37:29 Outcome And Wrap Up
39:46 Podcast Closing Notes
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