Heat Injury Management in the SAF - A Report by the External Review Panel on Heat Injury Management

Executive Summary

Background

In May 2018, MINDEF commissioned an External Review Panel on Heat Injury Management (hereinafter referred to as "The Panel") to examine the SAF's heat injury policies and processes. The Panel was headed by A/PROF MARK LEONG KWOK FAI, Senior Consultant, Department of Emergency Medicine, SGH, who was supported by:

a) A/PROF MARCUS ONG ENG HOCK, Senior Consultant, Department of Emergency Medicine, SGH;

b) A/PROF KELVIN CHEW TAI LOON, Director and Senior Consultant, Changi Sports Medicine Centre, CGH;

c) DR TEOH CHIN SIM, Director and Senior Consultant, Sports Medicine Centre, KTPH; and

d) A/PROF JASON LEE KAI WEI, Programme Director, Human Performance Programme, Defence Medical & Environment Research Institute, DSO National Laboratories.

General Impressions

The Panel found that the SAF's heat injury measures were generally sound and aligned with prevalent industry and foreign military practices. The Army's Training Safety Regulations (TSR) on hot weather operations were broadly similar to regulations promulgated by advanced armed forces , while the SAF's medical responses were closely aligned with the SAF-MOH Clinical Practice Guidelines 1/2010: Management of Heat Injuries. 

The SAF has put in place a broad range of heat injury prevention measures. It has also invested substantial resources to prevent and treat heat injuries. These investments include research studies, improved load-bearing vests and uniforms, specialised cooling equipment and a responsive casualty-evacuation system. The Panel also found that the training regimes provided to SAF medical officers and medics are in line with national requirements. 

Observations and Recommendations 

The Panel raised several observations and recommendations for the SAF's consideration.  The key themes underlying the recommendations were: 

a) Fine-tuning the SAF's heat injury prevention measures.

b) Ensuring early recognition and evacuation of heat injury cases. 

c) Providing effective cooling to heat injury casualties.

Fine-tuning heat injury prevention measures. The Panel suggested several additions to the SAF's range of heat injury prevention measures. The recommendations included improving heat injury awareness, fine-tuning work-rest cycles, extending the use of during-activity cooling and setting upper hydration limits.  The Panel also felt there was a need for the SAF to address impediments to self-reporting that may discourage soldiers from speaking up when they feel unwell. 

Ensuring early recognition and evacuation. The Panel emphasised that the early recognition of heat injuries was the most important element of their recommendations. Commanders, conducting staff and soldiers all have key roles to play in recognising signs and symptoms of heat injury in their fellow soldiers. They should then take action, as prescribed in the TSR, to ensure that first aid is rendered and casualties are evacuated as soon as possible. Commanders and medics should err on the side of caution because it is difficult to accurately determine the degree of heat injury. When in doubt, all suspected heat stroke cases should be evacuated to a medical facility, where they can receive further assessment and treatment.
 
Providing effective cooling. The Panel emphasised that the treatment of heat casualties should involve three key principles: (1) rapid cooling of body core temperature; (2) stabilising the casualties and evacuating them to hospital as early as possible; and (3) continuing the cooling process while en-route. 

a) The Body Cooling Unit (BCU) is the main cooling modality for treating heat injury casualties in the SAF. The Panel recommended that HQ MC should promulgate standardised heat injury treatment protocols to better guide the MOs, senior medics and paramedics who operate the BCUs. HQ MC should also establish formal escalation channels so that MOs can seek guidance and advice from senior SAF physicians when handling medical emergencies.  

b) While the BCUs have served the SAF well, research suggests that there are newer and more effective rapid cooling methods, such as cold water immersion and cooling suits. The Panel felt that the SAF should evaluate these methods, with a view to augmenting or eventually replacing the BCUs.  The SAF should also invest further in portable cooling equipment, which would allow casualties to undergo rapid cooling while being transported to a medical facility. 

Conclusion

The SAF has invested substantial effort and resources towards heat injury prevention and treatment. The resultant heat injury measures are generally sound and aligned with prevalent industry and foreign military practices. There is, however, scope for further enhancements and the Panel has surfaced several recommendations that we hope will help the SAF: (1) fine-tune its heat injury prevention measures; (2) ensure early recognition and evacuation of heat injury casualties; and (3) provide casualties with more effective rapid cooling.

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