After what may have been months of anticipation, you’ve finally reached the summit of your first 14er (jargon for 14,000 foot plus summits here in Colorado) on top of Mount Princeton. It is the afternoon. The weather report you read before you started on your journey from your hotel room, or maybe camping at the trailhead, suggested that the weather around the 7,500 feet you started at was going to lead to a pleasant day. You were going to have the bluebird skies, and grand vistas you saw on Instagram.
While you’re reaching for that summit beer (We’ve got tons to pick from here in Colorado. Dale’s Pale Ale is a great one to start with.), you notice your counterpart’s hair is not its usual self:
I can only hope it’s a relatively easy guess as to what is going on at this point. I am also sure that at least one of you is like:
Nick, really, lightning? It is worth the review, and I think it’s a great topic because there is a possibility of so many systems coming into play: logistics, safety, clinical care, planning… this is pre-hospital operational medicine, if there ever was.
We already know it kills around 27 people a year in the US, strikes about 243 people every year. And I’d agree with you. You may even go on to suggest certain statistics like:
- Your odds of being struck are 1/1,222,000.
- Being struck once in your 80 years of life, however, is 1/15,300.
- And the odds you’ll know someone struck by lightning? 1/1,530 (US Department of Commerce, NOAA, 2019).
- The overall ratio of lightning injuries to deaths is 10:1, with a 76% chance of sequelae in survivors: Neurologic sequelae include amnesia, paraesthesiae, and traumatic spinal injury. Tympanic membrane rupture occurs in 50% of survivors (Flaherty & Daly, 2016).
That’s important, as with most trauma, we’re more likely to see injuries and not death, but I think the sequelae issue a huge take-home. We need to push for these patients to have follow up and been seen in the ED and monitored for a length of time.
And I agree with you… but, hear me out about a few things as to I think we need think about it more:
Location Matters
Lightening issues are greatly based on location. Here in Colorado, we have more frequent lightning-related events (granted, Pennsylvania has the most deaths in 2020, both on deer stands) (US Department of Commerce, NOAA, 2020).
And worry not, Florida also makes the list, as do a wealth of other states, and the Pacific North West seems the overall safest place to be. Data lag is a thing, so I apologize for this map being a few years old. Still, I think it paints a decent picture, regionally speaking, that you need to be thinking about lighting, and remember, this is deaths, not strikes/injures which are significantly more:
These types of calls can be substantial operational and logistical undertakings…
Here in Colorado, we had an incident that happened last year where 8 hikers were injured after a rock was struck in the backcountry, plus their dogs: Multiple were knocked to the ground. Some needed assistance to be carried out of the backcountry, some had burns. One was transported. This was an enormous undertaking for a multitude of reasons, and while clinically things were overall benign, the logistics and operation issues faced where huge. While there are super interesting medical components to lighting streaks (Fear not, I plan to cover some.), I would not be me if I did not think about some operational issues.
- Operational Issues:
- Lighting strikes in the backcountry or at an event can become complex events very quickly. Whether it is in the bush, at a large-scale event, or even just one person who is trapped in a tree or on the water.
- These can quickly turn into an MCI, and triage is reversed when we deal with patients injured by lighting.
- Here in Colorado, and many other places, SAR teams are all volunteer-based, they can take valuable time to muster, deploy. They may suffer from a lack of staffing; thus making backcountry extrication of patients can be a huge issue.
- If this happens at a large venue, say a concert, the potential for secondary and tertiary injuries and medical events exist too. A panicking crowd post a lightning strike is probably not something your event medical team planned on dealing with.
- Team safety: are storms still going on? Will storms be a problem at altitude? What about for flights (HEMS does SAR work here, so even just locating the victims could be an issue.
- My organization is lucky to have a Chief who spent years working with the National Park Service and he is a huge proponent of using a GAR (GREEN/AMBER/RED) risk matrix to decide on everything from taking an IFT to a backcountry mission. If you are not considering this with every operation you do, I highly suggest you borrow this from the aviation and/or SAR world and apply it to your EMS operations.
- Overall scene safety: Is there still a threat of more lightning? Are you working under the ‘cone of safety’ that taller objects like trees or even your vehicles can provide? This is the type of call where you need to sit back, take that extra 10-second pause, and have a solid operational plan before you start medical care. In high altitude areas, a buffer zone of 30 minutes and/or ten miles of travel is suggested (Riddle et al., 2020). Obviously, during a response scenario, this is the danger that needs to be evaluated.
- Do you have a plan on how to stage your response vehicles in an area that received lighting strikes, or are you waiting until the storm threat has passed? I recently sat through a lecture on-scene safety and lightning by Dr. Hannah Heinrich, who works with my agency part-time as a data scientist. Still, she happens to be a lighting safety/mitigation expert from Germany. Her suggestion? Park close, and if you have something like a trunk/hatch to open, use it like an ad hoc Faraday Cage to help protect you.
- Lighting strikes in the backcountry or at an event can become complex events very quickly. Whether it is in the bush, at a large-scale event, or even just one person who is trapped in a tree or on the water.
Medical Issues
What I find fascinating about lightning injures is that they cover a considerable gambit of problems and possibilities and pathologies. I will venture a guess that most of the group reading this understands the fundamental issues of what may happen if you are struck directly or indirectly: trauma, neurological problems, both long and short term. How you encounter the lightning strike is also a critical factor in terms of death and injury severity.
You can have one of five types of contact with electricity:
- A rare direct strike and approximately 5 percent of all human-associated strikes.
- Contact is when a person is touching an object struck by lightning.
- Side splash makes up about 1/3 of all injuries and is when a current follows the path of least resistance.
- Ground current or step voltage makes up around half of all lighting related injuries. This is precisely what it sounds like when a current moves through the ground and strikes victims.
- The fifth and last is called an upward streamer, where the current moves up through the ground, the victim, and towards a lightning strike (Davis et al., 2012).
It’s important to remember that this is electricity, and like all electricity, it will follow the path of least resistance: nerve-> blood-> muscle-> fat-> skin-> bone.
Other basic considerations? If you find yourself in an MCI, things change if it involves lighting. Since a respiratory arrest is generally the issue with strikes that kill victims, during a lightning MCI, you reverse your triage scenario. Treating the dead first is the way to go, because many times they need respiratory support and/or cardioversion, both of which have a high chance of being successful (Zafren et al., 2005).
Neurological Issues
Perhaps the most exciting thing I found while researching this article is the instance Keraunoparalysis. I feel that this is worth covering because it looks like one of the findings we as pre-hospital providers could run into, and find it to be reasonably devastating on initial assessment. It is a transient paralysis of usually the lower limbs (Naik & Krishna, 2018). The Autonomic nervous system is affected, which causes excessive catecholamine release, which causes pallor, coolness, loss of pulses, nerve ischemia, and vasospasm of the limbs and spinal arteries; however, arterial perfusion seems to not be affected (Naik & Krishna, 2018). Other neurological issues may be delayed by even days, such as myelopathy or spinal muscular atrophy can occur (Pfortmueller et al., 2012). With this being the case, even if your patients seem okay, and went to refuse care, I encourage you to make sure they get to follow up in any way you can convince them.
Trauma
I feel like this is the give me for injuries related to lighting. Burns are probably the first thing that comes to mind due to the electricity, but I also encourage you to keep your mind open for other types of injuries: ever heard of shoes getting blown off a person who is struck by lightning? That’s because of exploding steam; rapid conversion of body moisture to steam and the subsequent explosion of pressure is what causes the patient’s shoes to go flying. Other low hanging signs and symptoms are trauma from being thrown and injuries from the blast itself, a thorough assessment seeking to look for blast injuries, to include hollow organs such as the lungs.
In Closing
Lightning strikes and their following impact on patients can be something of minimal impact or something entirely complicated, requiring full resuscitation and the highest level of pre-hospital care. I feel like it is a scenario we as providers can easily forget about, and what I wrote just touches the surface of what can go wrong, but I feel like they are the areas we most likely need to know about as pre-hospital providers. These scenarios are indeed where pre-hospital care needs to shine, not just clinically, but operationally in terms of rescue, MCI, or even event that has injured patients that requires a systematic approach.
Davis, C., Engeln, A., Johnson, E., McIntosh, S. E., Zafren, K., Islas, A. A., McStay, C., Smith, W. “Will” R., Cushing, T., & Wilderness Medical Society. (2012). Wilderness medical society practice guidelines for the prevention and treatment of lightning injuries. Wilderness & Environmental Medicine, 23(3), 260–269. https://doi.org/10.1016/j.wem.2012.05.016
Flaherty, G. T., & Daly, J. (2016). When lightning strikes: reducing the risk of injury to high-altitude trekkers during thunderstorms. Journal of Travel Medicine, 23(1), 1–2. https://doi.org/10.1093/jtm/tav007
Hill, K. (2011). The Science and Myths Behind Lightning Strikes | Science-Based Life. Science Based Life. https://sciencebasedlife.wordpress.com/2011/04/28/the-science-and-myths-behind-lightning-strikes/
Naik, S. B., & Krishna, R. V. M. (2018). A case of keraunoparalysis: A bolt from the blue. Indian Journal of Critical Care Medicine, 22(11), 804–805. https://doi.org/10.4103/ijccm.IJCCM_325_18
Pfortmueller, C. A., Yikun, Y., Haberkern, M., Wuest, E., Zimmermann, H., & Exadaktylos, A. K. (2012). Injuries, Sequelae, and Treatment of Lightning-Induced Injuries: 10 Years of Experience at a Swiss Trauma Center. Emergency Medicine International, 2012, 1–6. https://doi.org/10.1155/2012/167698
Riddle, M. S., Connor, B. A., Beeching, N. J., DuPont, H. L., Hamer, D. H., Kozarsky, P., Libman, M., Steffen, R., Taylor, D., Tribble, D. R., Vila, J., Zanger, P., & Ericsson, C. D. (2020). 2020 Hubei Lockdowns. Journal of Travel Medicine, 24(Suppl 1), S63. https://doi.org/10.1093/JTM
Sterling, J. (2020). Straight, No Chaser: Electrical Injuries and Lightning Strikes – Jeffrey Sterling, MD. Jeffreysterlingmd.Com. https://www.jeffreysterlingmd.com/2017/06/25/straight-no-chaser-electrical-injuries-and-lightning-strikes-3/
Sundermier, A. (2016). What to expect when you survive lightning – Business Insider. Buinsess Insider. https://www.businessinsider.com/what-to-expect-when-you-survive-lightning-2016-4
US Department of Commerce, NOAA, N. W. S. (2019). How Dangerous is Lightning?
US Department of Commerce, NOAA, N. W. S. (2020). National Weather Service Lightning Fatalities in 2020: 9.
Zafren, K., Durrer, B., Herry, J. P., & Brugger, H. (2005). Lightning injuries: Prevention and on-site treatment in mountains and remote areas: Official guidelines of the International Commission for Mountain Emergency Medicine and the Medical Commission of the International Mountaineering and Climbing Federation (ICAR and UIAA MEDCOM). Resuscitation, 65(3), 369–372. https://doi.org/10.1016/j.resuscitation.2004.12.014