Diagnostic Assessment — Sunstroke
Example 1 of 1 · fictitious patient
Diagnostic Assessment Sunstroke BOP Code: 32 of 2022 (Exertional Heat Illness) RH Code: 31 of 2022 (Exertional Heat Illness)
ADF History
The veteran, date of birth [withheld], Royal Australian Navy, Marine Technician, 25 October 1989 to 10 August 1996
Occupational History
As a Marine Technician in the Royal Australian Navy, the veteran performed outdoor duties aboard naval vessels in tropical and subtropical latitudes, particularly during postings to a frigate (latitude approximately 16.9°S, tropical North Queensland), a frigate, and a frigate (Marine Technician vessels operating in northern Australian waters).
These postings involved prolonged outdoor sun exposure during survey operations in equatorial and tropical conditions.
The occupational exposure to extreme heat and direct sunlight during Marine Technician duties is a significant risk factor for sunstroke (heat stroke/heat exhaustion)
History
The veteran experienced sunstroke during ADF service.
On 12 August 1993, whilst serving on a frigate, he was diagnosed with sunstroke after 9 hours on the gangway with no protection from the sun; he was badly sunburnt despite liberal application of sunblock cream and was treated with Panadol, cold fluids and Gastrolyte.
On review on 14 August 1993, the record noted the sun exposure and dehydration; he complained of headache, nausea, lethargy and some chills, and stated that he was still too ill to work.
He was referred from a frigate Sick Bay and admitted to RANH a frigate that day for bed rest and fluid replacement, with a final diagnosis of sunstroke (ICD 992.0), and was discharged to duty (Category 1) on the same day.
The veteran's service in tropical northern Australia (a frigate, approximately 16.9°S) as a Marine Technician working outdoors on naval vessels during survey operations would also have involved significant heat and sun exposure
Timeline
During service (1990 1997) — The veteran served in tropical latitudes including a frigate and aboard survey vessels in northern Australian waters.
Marine Technician duties involved prolonged outdoor work in extreme heat conditions.
12 Aug 1993 — ABSR the veteran (a frigate) was diagnosed with sunstroke after 9 hours on the gangway with no protection from the sun.
He was badly sunburnt despite liberal application of sunblock cream.
BP 120/70, temperature 37.2°C, pulse 80.
Treated with Panadol, cold fluids and Gastrolyte, with review in 2 days. "Sunstroke" 14 Aug 1993 — ABSR the veteran (a frigate) was reviewed following the sun exposure, with dehydration noted, and complained of headache, nausea, lethargy and some chills.
Temperature 36.8°C, chest clear, abdomen soft and non-tender.
He stated he was still too ill to work and was admitted to RANH a frigate. "Sun exposure" 14 Aug 1993 — Admitted to RANH a frigate, referred from a frigate Sick Bay with sunstroke, for bed rest and fluid replacement.
He still complained of nausea, weakness and headaches, with no vomiting, diarrhoea or abdominal pain; examination was unremarkable.
By 1500 hrs he was feeling much better and was discharged to duty (Category 1) on no medications.
The in-patient record states the activity at the time as "DUTY" and codes excessive heat (E900) as the external cause.
Final diagnosis sunstroke (ICD 992.0); 1 day ineffective for work. "Sunstroke"
1. What is the formal diagnosis of the condition claimed above?
Sunstroke / Heat Exhaustion (ICD-10: T67.0XXA).
Sunstroke is a heat-related illness caused by prolonged exposure to high temperatures and direct sunlight, characterised by elevated body temperature, headache, nausea, confusion, and potentially organ damage.
2 3.
Dates, confirmation: First symptoms: on or before 12 August 1993.
First presentation: 12 August 1993 (whilst serving on a frigate).
Confirmed: 12 August 1993 (clinical diagnosis of sunstroke by the medical officer), with a final diagnosis of sunstroke (ICD 992.0) on admission to RANH a frigate on 14 August 1993.
DRCA legislation.
Occupational exposure to heat and sun on duty; the documented episode followed 9 hours on the gangway with no protection from the sun whilst serving on a frigate (presenting to a frigate Sick Bay and admitted to RANH a frigate) with no protection from the sun, and the activity at the time was recorded as duty.
100% service-related
4. What do you consider to be the cause(s) of the condition in this veteran?
Legislation: The clinical onset of this condition was before 22 January 2010 (see
Date of Clinical Onset
Below), and it did not arise on warlike or non-warlike deployment (the veteran had no deployments).
This is therefore a DRCA claim.
Statements of Principles do not apply to DRCA claims, so there are no binding SOP factors for this condition.
The factors of the relevant Statements of Principles are applied below by analogy, as a guide to the causes of this condition that are recognised in the medical-scientific literature, and every factor of both the Balance of Probabilities and the Reasonable Hypothesis instruments is addressed.
Under the DRCA the question is whether the injury or disease arose out of, or in the course of, the veteran's ADF service, or (for a disease or an aggravation) whether that service contributed to it to a significant degree.
Plausible links to service outside the SOP factors are set out below.
The absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Definition: The recorded diagnosis was sunstroke (ICD 992.0).
The veteran's recorded features, namely headache, nausea, lethargy, weakness, chills and dehydration, without confusion, altered consciousness or a recorded temperature above 40°C, are those of heat exhaustion (also known as heat fatigue or heat stress), which the SOP includes within exertional heat illness, rather than heat stroke as the SOP defines it.
Causative Factors — Balance of Probabilities (Statement of Principles concerning Exertional Heat Illness, No.
32 of 2022) Factor 9(1): undertaking physical activity at a minimum intensity of at least 3 METs in a hot environment at the time of the clinical onset of exertional heat illness — MET - The Outpatient Health Record of 12 August 1993 records nine hours of gangway duty on a frigate without protection from the sun, and the in-patient record of 14 August 1993 codes the external cause as excessive heat.
The SOP does not define a hot environment, but nine hours of direct midsummer sun without shade, leaving him badly sunburnt and dehydrated, plainly was one, and the SOP's note recognises prolonged activity and obesity (his BMI was about 32) as adding to the risk.
Standing at the gangway is below 3 METs, but the duty also involves walking about the brow and upper deck and climbing the gangway and ladders (about 3 to 5 METs); on a conservative estimate of a quarter of the watch, that is over two hours of activity of at least 3 METs in a hot environment.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Exertional Heat Illness, No.
31 of 2022) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(1): undertaking physical activity at a minimum intensity of at least 3 METs in a hot environment at the time of the clinical onset of exertional heat illness — MET - Before presenting on 12 August 1993 the veteran had stood nine hours of gangway duty on a frigate in direct midsummer sun without shade, becoming badly sunburnt and dehydrated, and the in-patient record of 14 August 1993 codes the external cause as excessive heat.
Standing at the gangway is below 3 METs, but the duty also involves repeated walking about the brow and upper deck and climbing the gangway and ladders at 3 METs or more, so over the nine hours he undertook physical activity of at least 3 METs in a hot environment at the time of onset.
Other Plausible Links to Service The illness arose out of, and in the course of, his duties.
The Outpatient Health Record of 12 August 1993 attributes it to nine hours of gangway duty on a frigate with no protection from the sun, and the in-patient record of his admission to RANH a frigate on 14 August 1993 records the activity at the time as duty and codes excessive heat as the external cause.
Standing a prolonged gangway watch in direct summer sun without shade was a requirement of his service, so the exposure that caused the illness was a service exposure whatever view is taken of the SOP's exertion threshold.
The sunburn recorded on 12 August 1993, when he was badly sunburnt despite liberal application of sunblock cream, is itself a heat-induced burn caused by solar radiation.
It satisfies factor 9(4) of the Statements of Principles concerning heat-induced burn (BOP No.
2 of 2024 and RH No.
1 of 2024), exposure to solar radiation sufficient to cause at least erythema at the affected area at the time of onset; it arose from the same gangway duty, and his very fair complexion and blue eyes, noted by the ophthalmic surgeon on 25 November 1992, made him more susceptible to it.
Conclusion the veteran's sunstroke, which in the SOP's terms was heat exhaustion, was caused by nine hours of gangway duty on a frigate in direct midsummer sun without shade immediately before its onset on 12 August 1993, during which he undertook physical activity of at least 3 METs in a hot environment.
The naval hospital recorded the activity as duty, so the illness arose out of and in the course of his service, and the accompanying sunburn is a heat-induced burn caused by the same service exposure.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's sunstroke is found not to have arisen out of his service, the following factors address whether service rendered after its clinical onset on 12 August 1993 aggravated it or contributed to it in a material degree; his symptoms persisted until his admission to RANH a frigate on 14 August 1993.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Exertional Heat Illness, No.
32 of 2022) Factor 9(2): inability to obtain appropriate clinical management for exertional heat illness — NOT MET - Applying Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), there was no inability to obtain appropriate clinical management: he was treated on 12 August 1993 with fluids, rehydration salts and 48 hours off duty, and when still unwell on 14 August 1993 he was admitted to RANH a frigate that day and recovered fully; the loss of his medical record in 1996 had no bearing on this care.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Exertional Heat Illness, No.
31 of 2022) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(2): inability to obtain appropriate clinical management for exertional heat illness — NOT MET - Assessed objectively and subjectively as Brew v Repatriation Commission (Full Federal Court, 10 September 1999) requires, the veteran received prompt treatment on 12 August 1993 and hospital admission for bed rest and fluid replacement on 14 August 1993, after which he recovered fully; there was no inability to obtain appropriate clinical management
Sequelae, Unintended Consequence, Inability
No specific sequelae documented.
Not an unintended consequence.
Loss of PM168 records — MET
Date of Clinical Onset
Sunstroke is an acute condition.
Its date of clinical onset is the date of the injury or illness itself, as recorded in the contemporaneous service record.
Later investigations, reviews and imaging record the investigation, treatment or confirmation of the condition; they are not the date of clinical onset.
Date of injury / illness: 12 August 1993 — sunstroke after 9 hours on the gangway with no protection from the sun whilst serving on a frigate [CHART REVIEW document].
The later records, including the admission to RANH a frigate on 14 August 1993, concern investigation or follow-up and do not alter the date of clinical onset.
Date of clinical onset: 12 August 1993.
This date falls within the veteran's ADF service (25 October 1989 10 August 1996).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
