Feeling hot and bothered?

I’m writing this just after the hottest day of the year so far, when it’s still a positively chilly 24 degrees outside (!) My heat related stress was exacerbated when every news outlet was advising patients “if you’re concerned about the effects of heat, speak to your GP”. Now I know general practice is the catch all for most things, but it made me think that I didn’t recall ever studying heat exhaustion, heat stroke or risk minimisation at medical school. Was I the only one to miss that lecture?

So I turned my brain to the evidence and guidance. Because otherwise a patient asking my advice would be told to buy a giant pack of Calippos, strip down to their underwear and sit in front of a fan until it cooled down, none of which feels like especially robust medical advice. I was delighted to find there are some actual guidelines that outline what we should be considering for our patients when this type of weather strikes. The two most useful are from the World Health Organisation albeit from 2011 but heatwaves haven’t changed that much, and the hot-off-the-press (pun intended) guidance from the Society for Acute Medicine (SAM) written just this year. 

The WHO guide is written from a public health perspective but has specific sections for GPs including a useful chapter for care home managers and on looking after patients in care settings. If you have care homes registered with you, or a PCN care home team if you’re in England, this is well worth sharing with them. 

The SAM guide is written specifically for UK health professionals, and there are a number of actions that would be a brilliant Quality Improvement Activity for your practice. I’ve summarised these into 5 areas below:

Monitor the MET office weather alerts and be ready to take action when a red or amber alert is issued for your area. Update your practice website with the following simple advice that applies to all patients:

• Stay hydrated—water or juice over alcohol, avoid sitting in the sun for >20 minutes
• Wear loose, light clothing and high-SPF sunscreen; avoid the sun between 11 am–3 pm
• Store medications safely—avoid leaving inhalers or EpiPens in cars or in direct sun

The NHS website always has up to date hot weather guidance, and is another excellent resource to share with patients. 

Make all staff aware of the high-risk groups of patients:

• Over-65s, those with cardiac, respiratory, renal, neurological, or psychiatric comorbidities
• Diabetics, pregnant women, young children, those on specific meds
• Isolated individuals, those experiencing homelessness, manual outdoor workers.

Consider if these groups need flagging, or to be triaged in a different way during episodes of extreme heat. 

Medications that interfere with thermoregulation or fluid balance are particularly problematic. Consider reviewing patients on these, and issuing advice about dose reduction, temporary drug breaks, or extra monitoring during hot weather:

• Diuretics, ACE‑inhibitors, ARBs, NSAIDs, SGLT₂-inhibitors - risk of AKI & electrolyte disturbance.
• Digoxin, lithium, antiepileptics - toxicity in volume-depleted states
• Antipsychotics, antidepressants, anticholinergics, beta-blockers - can disrupt thermoregulation or sweating)
• Photosensitizing drugs - e.g. doxycycline, amiodarone
• Transdermal patches - heat may alter absorption; heat rashes may dislodge. Nobody needs their analgesia or HRT to stop working while tackling a heat wave!

Managing heat related conditions depends on diagnosing them correctly. Let your clinical staff and care navigators know the signs and symptoms to look out for, and manage patients depending on severity:

• Heat rash/sunburn: Cool compresses, antihistamines, simple analgesia. While there are lots of lotions and potions recommended anecdotally, emollients are just as effective and advised by NICE for managing simple burns. 
• Heat exhaustion (Patient temp 38–40°C): Oral fluids with electrolytes; avoid NSAIDs or paracetamol if hypotensive.
• Heatstroke (Patient temp >40°C): Emergency referral. These patients need rapid cooling, IV fluids and electrolyte correction with close monitoring.

And last but not least, look after yourselves and your staff. The SAM advice recommends closing curtains or blinds whenever possible during the day, providing chilled water and encouraging breaks for all staff in wherever the coolest part of the surgery is. Ensure your team monitor fridges and medicine storage to keep temperatures <25 °C. And of course, don’t forget to exclaim every 10 minutes, “phew, it’s too hot for me!”