050 - Twice Burned: How One Special Warfare Trainee Beat Repeat Exertional Heat Stroke
Exertional Heat Stroke (EHS) is a silent killer in tactical training. When it happens twice, despite gold-standard treatment, it forces a new conversation about readiness, recovery, and who gets to stay in the fight.
This case study from the U.S. Air Force outlines how one Special Warfare trainee survived two EHS events and still made it back. The protocol that followed offers a blueprint for managing complex heat illness cases in high-performance populations.
WHAT THEY FOUND:
Initial Event: A 23-year-old Special Warfare trainee collapsed during a 4-hour training event. Rectal temperature: 41.61°C. He was treated with immediate ice water immersion and completed standard recovery.
Second Event (4 weeks later): After a textbook reacclimatization process, he collapsed again. Though core temp didn’t hit 40°C, symptoms and CNS disruption confirmed repeat EHS.
The 3-Step Protocol That Worked:
Prolonged Recovery (4 months)
No heavy heat exposure
Maintenance of fitness in controlled environments
Heat Tolerance Testing (HTT)
VO2max: 58.9 mL/kg/min
Normal thermoregulation confirmed via the Israeli Defense Force model
Stepwise Reacclimatization
Gradual return to hot training
Completed 22-week pipeline without further incident
WHAT THIS MEANS:
Not every case of EHS follows the same playbook. Some recover in 3 weeks. Others need 3+ months. And if return-to-duty timelines don’t account for the hidden variable, acquired heat intolerance, you risk sending a ticking time bomb back into the field.
The use of HTT, though controversial, provided objective proof of recovery. More importantly, this case shows that with individualized recovery timelines, structured protocols, and fitness-supported HTT, warfighters can return, even after a second EHS.
TACTICAL IMPLICATIONS:
Don’t Assume Full Recovery After One Protocol: Heat tolerance doesn’t follow a clock—some cases need 12–16 weeks, not 4.
Use HTT to Confirm Thermoregulation: Objective data beats guesswork when careers are on the line.
Build Fitness Before Testing: VO2max and acclimatization can dramatically influence HTT outcomes. Prepare accordingly.
Adopt Stepwise Reacclimatization: Use layered return-to-training models (e.g., Air Force 7-step protocol) that allow safe reintegration.
Create DoD-Wide Guidelines: This case exposes a gap—current return-to-duty protocols vary by branch. Standardization could save lives.
QUESTIONS TO CONSIDER:
How long do you wait before clearing someone for return after EHS, and is it enough?
Are you using heat tolerance testing or relying on subjective reports?
Does your training pipeline account for heat illness history or just assume resilience?
Could your recovery protocols be underestimating acquired heat intolerance?
If this were your teammate, would you trust their recovery or demand proof?
Caraway JJ, Shepard J, Hintz C, Butler CR. Management of a Special Warfare Trainee With Repeat Exertional Heat Stroke: A Case Study. J Sport Rehabil. 2023;32(6):719-724. Published 2023 Jun 7. doi:10.1123/jsr.2022-0324