Page 33 - JSOM Summer 2024

understanding motivation is crucial for designing effective pre- selection processes could aid in identifying individuals prone
vention and intervention measures. to possess high levels of motivation. Furthermore, establishing
intervention thresholds, where coaches, medics, or command-
The implications of our findings for practical applications in the ers intervene when an individual’s behavior appears to place
military and athletic realms are also multifaceted. Certainly, high them at risk, could be beneficial. As the effectiveness of exces-
motivation is the “gold standard” for successful military service; sive motivation mitigation methods have not been validated,
military culture and training environments inherently foster and future research in this area is necessary. Objective measures,
reward a strong intrinsic drive to accomplish tasks. Military such as gait analysis, offer potential means to detect early
schools such as Special Forces Assessment and Selection, Ranger signs of heat illness in real time, thereby allowing for timely
School, Security Forces Assistance Brigade selection, and Air- intervention before disaster strikes. 38–40 However, gait analysis
borne School, as well as the more routine environment of Basic coupled with real-time, non-invasive estimation of core tem-
Combat Training provide and encourage a multitude of oppor- perature is still in development and further refinement is nec-
tunities for warfighters to challenge themselves physically and essary before fielding such a solution.
mentally. The prestige associated with achievement and the im-
pact of such achievement on unit assignments in these settings, Limitations
combined with the fact that being goal-oriented and having a While case series play a valuable role in medical research by
“mission first” mentality are desirable traits for selection and providing insights into rare diseases or events such as EHS it is
advancement, at least partially explains the confluence of highly imperative to acknowledge their inherent limitations. One of
motivated individuals in these cohorts. the principal drawbacks is the lack of a control group, which
makes it challenging to establish causation or confidently at-
Short of canceling an event or modifying the conditions to tribute observed outcomes solely to an individual risk factor
reduce risk, it is difficult to mitigate the role of excessive mo- such as motivation. Additionally, patients included in this case
tivation in the etiology of EHS, but it is not impossible. It is series are representative of a very specific population of mili-
likely helpful to focus on foot march and run events, as we tary members aspiring to accomplish challenging and stressful
have previously shown that over 80% of all EHS casualties at physical tasks. The small sample size inherent in a case series
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Fort Moore occur during these events. While empirical data thus may limit the generalizability of findings and increase sus-
demonstrating effectiveness are lacking, several strategies have ceptibility to bias.
been implemented in various U.S. Army training units.
Furthermore, the retrospective nature of the case series limits
First, trainees can be educated to recognize that despite their the completeness of available data. While each patient ref-
best efforts, it will be impossible in hot and humid conditions erenced in the case series was evaluated at the Martin Army
for them to replicate their best performance from cool or tem- Community Hospital and the Army Heat Center, which thereby
perate conditions and that they should adjust their pace (and provided some degree of standardization in the associated clin-
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performance expectations) accordingly. Second, the role of ical notes, it is important to recognize that specific character-
acclimatization should also be emphasized in education re- ization of “motivation to excel” is not routine data collected
garding EHS prevention. Indeed, two of the cases outlined in the clinical setting. Indeed, while the role of motivation in
above involved Soldiers who had arrived at Fort Moore from EHS has been acknowledged by reputable bodies such as sports
cooler areas of the country less than one week prior to com- medicine organizations, the U.S. Army, and NATO, the quanti-
mencing their training. fication and systematic assessment of this factor remains chal-
lenging. Accordingly, the retrospective nature of this case series
However, during the conduct of a specific event, unit leaders precluded the ability to administer a validated instrument for
should not rely on the individual Soldier’s understanding of measuring motivation at the time of event occurrence, thereby
his/her limitations and other control mechanisms can be im- requiring the authors to make a clinical judgment based on pa-
plemented. Some schools provide incentives for the fastest fin- tient responses in a clinical interview.
isher of an event. Incentives such as this should be curtailed
when the risk of EHS is high. In order to control the pace of Conclusions
the fastest individuals, a cadre member could be placed at the
head of the group, with instruction that no one is permitted to Physiological thermoregulation in the heat is very effective in
exceed the cadre member’s pace. Similarly, a cadre member can humans, and in most cases, behavioral thermoregulation can
maintain the minimal required passing pace (e.g., 15-min/mile be seen as an adjunct—to assist when physiological mecha-
for the Army standard 12-mile foot march), with participa- nisms reach their limits. In the cases reviewed here, behavioral
tion terminated for any individual who cannot maintain that choices, originating at least in part from the motivation of the
minimum pace. Last, in the initial entry training environment, individual to excel, had the opposite effect, augmenting risk
keeping the group in formation, with the pace of the entire and contributing to collapse from EHS. Given that competi-
group directly controlled by Drill Sergeants, has anecdotally tive atmospheres within the military and in sport will attract
appeared to be a successful strategy. However, we recognize personnel who are highly motivated to accomplish tasks and
that many courses are designed in part to assess individual goals regardless of the environmental or physiological limits
motivation, limiting the practicality of some recommendations involved, leaders must use creative strategies to mitigate this
in certain training environments. risk. This becomes especially crucial in scenarios in which indi-
viduals may be unable or unwilling to self-modulate their work
Future Directions output. Future research should aim to increase our ability to
Given the challenging nature of assessing motivation from a quantify the impact of motivation, explore comprehensive as-
distance, our review suggests several potential approaches to sessment methods, and translate these insights into actionable
confront this issue. Personality assessments prior to training or measures that mitigate EHS risk effectively.

Motivation to Excel and Exertional Heat Stroke | 31