— Return-to-duty flow chart per AR 40-501. 

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... In general, heat injury rates declined with increasing age such that crude rates were more than 10 times higher among soldiers less than 20 as compared to those older than 39 years old. Rates declined among males in a linear fashion over the entire age range (Figure 1). Rates among females also fell from a peak for <20 year olds to a sharp declined with increasing age. Although a sharp drop was noted for women between 20 and 24 years, no explanation for this can be offered. 4 The rate of heat injuries in 2002 was the highest annual rate over the preced- ing five years (Figure 2). The relatively high overall rate in 2002 was attribut- able primarily to an increase in the number of ambulatory visits, which led to an increased number of cases being reported. Of note, the rate of hospitalizations for heat injuries in 2002 was similar to rates for the prior four years (and slightly lower than the rate in 2001; Figure 2). Whatever the explanation(s) for increasing rates, exertional heat illness is a clear and significant threat to the health and operational effectiveness of warfighters. 4 To understand how the military approaches return-to-duty for soldiers, airmen, sail- ors, and marines after a heat injury, some background information warrants review. The military uses a system of regulations to govern the suitability of individuals for military service. Army physicians must refer to medical fitness standards provided in Army Regulation (AR) 40-501. 3 This regulation lists various medical conditions and physical defects that may render a soldier unfit, details how to appropriately “profile” or restrict a soldier, and specifies when a soldier should be referred to a formal medical hearing or board to determine fitness for further duty. A physical profile is a serial system used by the military to evaluate the dif- ferent body systems and how they relate to military duties. Because the analysis of the individual’s medical, physical, and mental status is important in future assignments and welfare, the functional grading must be executed with great care. The purpose of the physical profile is to provide an index of overall functional capacity. The functions of the individual are evaluated under six different areas known as “P-U-L-H-E-S.” The “P” is for physical capacity or stamina, “U” is for the upper extremities, “L” is for the lower extremities, “H” is hearing and ears, “E” is for eyes, and “S” is for psychiatric functioning. Table 1 presents the numeric values assigned for quantifying the ability to function in these areas. A lower functional capacity is designated by a higher number and can be temporary or permanent. Table 2 presents a guideline for each of the six different areas and the level of functional capacity. For example, a healthy soldier would have a 1 for each of the six areas. A heat stroke victim may be assigned a temporary 3 [T-3] in the “P” or physical capacity category, eg, P-[T-3]. The numeric designator is not an automatic indica- tor of “deployability” or assignment restrictions, nor does it indicate an immedi- ate referral to a Medical Evaluation Board (MEB) and then possibly a Physical Evaluation Board (PEB). Rather it is a subjective indicator of functional capacity. The conditions or defects requiring an MEB/PEB are listed in AR 40-501 Chapter 3 (Medical Fitness Standards for Retention and Separation, Including Retirement). The MEB is an informal proceeding wherein at least two physicians evaluate the medical history of a soldier and determine how the injury/disease will respond to treatment protocols. The physician uses the MEB process to construct a detailed narrative summary of the soldier’s condition and prognosis, which will be forwarded to the PEB. The PEB is a formal hearing process where the soldier’s condition is discussed and evaluated so that a final determination can be made concerning retention, transition to another military specialty, or separation from the service with disability. Heat exhaustion is defined in AR 40-501 as collapse, including syncope, during or immediately following exercise—heat stress, without evidence of organ damage or systemic inflammatory activation. Individual episodes of heat exhaustion are not cause for MEB referral; however, soldiers suffering from recurrent episodes of heat exhaustion (three or more in less than 24 months) should be referred for complete medical evaluation to determine contributing factors. If no remediable factor can be identified for causing recurrent heat exhaustion, the soldier will be referred to an MEB. Heat stroke is defined in AR 40-501 as a syndrome of hyperpyrexia, collapse, and encephalopathy, with evidence of organ damage and/or systemic inflammatory activation, which occurs in the setting of environmental heat stress. Heat stroke is an automatic MEB referral. As clearly stated in AR-40-501, all soldiers are referred to a MEB after an episode of heat stroke to determine when and if they can return to duty (Figure 3). If the soldier/airman fully recovers clinically, which is determined by normalization of labs (electrolytes, creatinine, creatine kinase, liver function tests) and normal mental status, or if a circumstantial contributing factor to the episode can be identified, the MEB may recommend a trial of duty with a P-[T–3] profile, which restricts the soldier/airman from performing vigorous physical exercise for periods longer than 15 minutes. Maximal efforts, such as the Army Physical Fitness Test (APFT) two-mile run are not permitted. If the soldier/airman has not exhibited any heat intolerance after three months, the profile may be modified to P-[T–2] wherein normal, unrestricted work is permitted; however, maximal exertion and significant heat exposure, such as wearing Mission Oriented Protective Posture (MOPP) IV, are still restricted. If no further heat intolerance is manifest, particularly during a season of significant environmental heat stress (working in the spring, summer, and fall exposed to the heat or in a vehicles/building with an increased heat index), the soldier may resume normal activities and return to duty without a PEB. Any evidence of significant heat intolerance during the period of restriction, or subse- quent to resumption of normal duty, requires a referral to a PEB. 3 These general guidelines are for return to duty after a heat injury, but some units have their own specific guidelines. The following is an example at Womack Army Medical Center in North Carolina, home of the 82nd Airborne. 5 Their guide- lines state two groups of patients will generally exist, although categorization is sometimes unclear: Group A is Mild Exertional Heat Illness and defined as heat exhaustion, exertional dehydration, heat cramps, potential hyponatremia. Group B is designated as having Severe Exertional Heat Illness (defined as heat stroke) or Rhabdomyolysis. Group A patients are usually alert, with appropriate behaviors, near normal and rapidly stabilizing vital signs, and able to drink fluids. Such patients may receive care outside of the hospital. However, upon realization that the patient might not fully recover within one hour, evacuation to an emergency department should be quickly arranged without further delay. Group A patients may progress to group B if they are not identified as having heat exhaustion. Transitioning to group B can occur rapidly with little advanced warning and can lead to inadequate treatment of these patients. Patients categorized as group B typically present with a history of mental status changes or amnesia, a history of syncope or seizure, unable to drink fluids, rectal temp >104°F, systolic BP <90 or orthostatic symptoms, and/or severe muscle or abdominal pain (or numbness). Treatments, which include rapid cooling (preferably with ice bath), must be aggressive for those who transition to group B. This group will require laboratory evaluation, follow-up the next day, and profiling P-[T-4]. All group B patients will be evaluated in an emergency department, with immediate treatment beginning before and continuing into evacuation. Mildly ill patients who appear to be fully recovered in the emergency depart- ment and have no laboratory abnormalities may return to light duty the next day and limited duty the following day; however, important deficits are sometimes subtle or delayed, and the patient should be carefully observed. Strenuous exercise (eg, APFT, airborne operations, road marching) should be avoided for several days. Patients not fully recovered and those with laboratory abnormalities will require follow-up by a residency-trained physician and a laboratory evaluation on the fol- lowing day. They should also be referred to preventive medicine for reporting and MEB referral if necessary. Seriously ill patients require hospitalization. This will generally include those with delirium, obtundation, coma, persistent altered mental status, shock, persistent electrolyte abnormalities, creatinine (Cr) >2.0 (milligrams per deciliter, mg/dL) or creatine kinase (CK) >4,000 U/L, and abnormal liver function tests (Aspartate aminotransferase-AST, Alanine transaminase-ALT). As with mildly ill patients, seriously ill patients should be referred to preventive medicine for reporting, fol- lowing-up of laboratory review, and MEB referral upon hospital discharge. All patients should remain on P-[T-4] profile, in quarters ( where the soldier is staying), or convalescent leave ( sick days) until all symptoms and laboratory tests have returned to normal (eg, CK <700 U/L, Cr <1.4 mg/dL). Also, a preventive medicine clinic must clear the patient (for reportable cases). When fully recovered, the patient may gradually resume exercise at his/her own pace and build up to maximal exercise over several weeks. A diagnosis of heat exhaustion or exertional dehydration must be reported if medical intervention is required or when there is more than four hours of lost duty time. Heat stroke ...