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activity. Organizational factors include training regulations re- project was to evaluate a series of five cases of EHS treated at
garding work-rest cycles, rehydration regimens, exercise inten- Martin Army Community Hospital at Fort Moore, GA. This
sities that match physical fitness, and training schedules that case series was analyzed for patterns to support additional hy-
avoid the hottest hours of the day. Minard’s paradigm served potheses generation regarding the role of motivation in EHS
as an early basis for safety guidelines issued by the U.S. Marine occurrences.
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Corps. Further elucidation of such risk factors has led mili-
tary communities to employ measures to decrease risk of EHS, Case Series Methodology
such as heat acclimatization, work/rest guidelines, and hydra- We conducted a case series review of five cases of EHS that
tion strategies. 14,22 Despite such prevention strategies and pol- occurred between 2020 and 2022 in military personnel treated
icies, heat illness-related mortality and morbidity still occur at Martin Army Community Hospital, Fort Moore, GA. As
with regularity among military personnel. 23,24 all information used in this report was originally collected for
non-research purposes only as the result of clinical experience,
Motivation to Excel as an EHS Risk Factor the hospital’s Human Protections Administrator determined
One risk factor that has been referenced in the literature as that IRB review was not required. After being treated, in ac-
potentially linked to EHS, but not well quantified, is that of cordance with the standard of care, each patient reported for
individual motivation to excel. This concept describes situa- follow-up evaluation by clinical team members of the Army
tions where highly trained military personnel and athletes ex- Heat Center, Fort Moore, GA, which provided narrative de-
ert themselves beyond their physiological limits because of a tail regarding the circumstances surrounding the onset of EHS.
desire to complete tasks and goals. 9,25,26 Indeed, several review The cases were preliminarily reviewed and deidentified by an
articles have qualitatively included “motivation” as a risk fac- active-duty physician before being qualitatively analyzed and
tor for EHS. 23,27–29 summarized in narrative form with particular attention to the
extent and contribution that motivation to excel contributed
Behavioral thermoregulation is essential to the maintenance to the incidence of EHS. Data detailing each case is summa-
of body temperature within a safe range, particularly when rized in Table 1.
physiological thermoregulation is overwhelmed or limited. An
important aspect of behavioral thermoregulation is a volun- Case 1
tary reduction in exercise work rate (intensity) when exercis- In September 2020, a 24-year-old female 1LT Ranger Candi-
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ing in a hot environment. For example, an investigation into date who had arrived at Fort Moore four days earlier, with
the effect of a simulated heatwave on the labor productivity no significant reported medical history, presented to the emer-
and physiological strain experienced by workers in the manu- gency department (ED) after becoming incapacitated during a
facturing industry found self-pacing in the form of unplanned 12-mile ruck march. Ambient weather conditions at the time
breaks to be a behavioral means of thermoregulation, in that of the event were temperature 71.4°F, 92% relative humid-
the behavior of taking breaks prevented the laborers from ity (RH), and a wet-bulb globe temperature index (WBGT) of
overheating. 31 70.4°F. During the event, she experienced dizziness and ulti-
mately lost consciousness. The patient was cooled by cold wa-
However, it appears that under certain conditions, motivated ter immersion. Initial core temperature taken by medical staff
individuals ignore typical internal (physiological) or external was noted as 107.5°F. The patient returned to normal menta-
(guidance) signals that would otherwise indicate the need for tion prior to the arrival of emergency medical services (EMS).
breaks, slower pacing, or other behavioral thermoregulatory During the heat clinic follow-up visit, the patient remarked
responses. This observation suggests that behavioral limits can that she was on “a personal best pace” prior to collapse. It
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be overridden through motivation. For instance, Goforth is important to note that the patient’s home duty station was
and Kazman specify high motivation as an intrinsic risk fac- in a cold weather location, thus she was very likely not ac-
tor for heat illness, with the assessment that military training climatized to the south Georgia heat and humidity. Further
includes the indoctrination of military culture, to include a questioning revealed a high level of motivation to succeed in
“mission first” mentality, which can lead motivated persons to Ranger School, as at that time fewer than 50 women had suc-
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ignore important physiological warning signs. Notably, Shi- cessfully completed the course and earned the Ranger tab.
bolet et al. reported nearly 50 years ago, “the tragedy of heat
stroke is that it so frequently strikes young, highly motivated Case 2
individuals in military training or professional sports, who un- In March 2021, a 21-year-old male PVT in his third week of
der other circumstances would have rested when tired, drank basic infantry training, with no significant reported medical
when thirsty, or remained at home when ill.” Accordingly, history or past heat injuries, presented to the ED after becom-
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the American College of Sports Medicine and National Ath- ing incapacitated during an obstacle course training event.
letic Trainers’ Association both recognize motivation as a risk Ambient conditions were temperature 63°F, 80% RH, and a
factor in competitive athletes, while U.S. Army Technical Bul- WBGT of 67.8°F. The patient reported experiencing narrowing
letin, Medical (TBMED) 507, Heat Stress Control and Heat vision and ultimately was observed by cadre to lose conscious-
Casualty Management, as well as the NATO guidance for the ness. The patient was cooled with ice sheets for 15 minutes
Management of Heat and Cold Stress both acknowledge that prior to the arrival of EMS. Core temperature obtained by
motivation to excel among military personnel can be a risk EMS personnel was 100.4°F. Per EMS, the patient had altered
factor for EHS. 14,15,34,35 mentation with gradual improvement during transport to the
hospital. Subsequent interview revealed that the patient was
The motivation to excel in tasks with high standards of one of several individuals selected to complete the obstacle
achievement appears to create an environment in which dis- course a second time, as a competition between fellow train-
proportionally elevated exertional heat illness casualties occur. ees, and that he was highly motivated to excel when provided
With this information as a background, the aim of the present the opportunity.

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