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SINGAPORE: The supervising officer of an 8 km fast march for national service trainees repeatedly rejected suggestions to immediately evacuate military officer Dave Lee Han Xuan, who could not walk properly and was drooling at the end of the march.
Details of the incident, as well as multiple protocol violations by the supervising officer, came to light on Wednesday (January 13) at the opening of a forensic investigation into the death of CFC Lee.
According to a police investigation report, Captain Tan Baoshu assessed that Corporal First Class (CFC) Lee was suffering from physical strain rather than heat injury and rejected a suggestion to evacuate him to the medical center, asking them to wait.
He also turned down a suggestion to administer an IV drip to CFC Lee, who was disoriented, unable to swallow fluids and was breathing heavily.
CFC Lee was evacuated just 40 minutes later, which a medical expert testified was “really too long,” and then died of heat stroke with multiple organ failure at age 19.
The court heard that CFC Lee had started the march along with the other military personnel at 6.45 am on April 18, 2018. He seemed fine and was able to talk to his superiors in the last kilometers.
During the last two kilometers, he informed a first sergeant that he had a calf cramp and was allowed to stop to stretch. He continued to take breaks throughout the final leg.
CPT Tan, the commanding officer of the Support Company, 1st Guards Battalion and the supervising officer of the march, joined CFC Lee for the last 300 meters of the march.
CFC Lee crossed the finish line at 8.25am, within the required 84 minutes after accounting for the mandatory rest period, and fell to his knees.
FELL ON THE KNEES AT THE END OF MARCH
He had the time recorded and was helped to get to a rest area, but he swayed as he walked there and his speech was washed away, the court heard.
He was observed to be incoherent, unresponsive, drooling from his mouth, and breathing heavily. They took off his equipment and unbuttoned his uniform. Following CPT Tan’s instructions, they applied ice packs to his neck, armpits, and groin and poured water onto his face.
CFC Lee was also doused with water from a mobile cooling unit, but was unable to swallow the isotonic water that was administered to him, and the liquid came out of his mouth.
CPT Tan observed that CFC Lee was disoriented, unresponsive, breathing heavily, and unable to follow instructions. However, he assessed that he was experiencing physical exertion rather than a heat injury.
When someone suggested evacuating him to the medical center, CPT Tan told him to wait as CFC Lee was suffering from physical strain and would recover. He did not order the immediate evacuation of CFC Lee, breaking protocol that states that soldiers suspected of suffering heat injuries must be evacuated immediately.
CPT Tan also rejected another suggestion to administer an intravenous drip, which is also stipulated in the guidelines for the unconsciously wounded or those who cannot drink water.
DIRECTED CFC LEE TO BE COVERED WITH EARTH SHEET
Instead, CPT Tan ordered CFC Lee to cover himself with sheets, as his arm felt cold. They covered him from the neck down with the sheet and then from the pelvis down.
Fifteen minutes after CFC Lee first collapsed, CPT Tan gave approval to fire the security vehicle, saying CFC Lee could be evacuated on a stretcher. He did not verify CFC Lee’s condition before doing so.
The firing of the security vehicle was contrary to the fast-moving guidelines, which stipulate that the vehicle must remain on site for a response evacuation.
At approximately 8:45 a.m. M., An off-duty doctor passing through the parade square met CFC Lee and treated him. He evaluated him and told CPT Tan that he should be evacuated to the medical center immediately.
CPT Tan told her that they should wait another five to 10 minutes to see if her condition improved. The doctor applied an oxygen mask to CFC Lee as he was panting.
At 8.50 a.m. M., Another person urged CPT Tan to evacuate CFC Lee without further delay, but CPT Tan responded that they should wait another five minutes.
CFC Lee was finally placed on a stretcher around 9 am and taken to the medical center on foot, arriving at 9:05 am. His temperature had not been taken at any point between his collapse and his arrival at the medical center.
ARRIVAL AT THE MEDICAL CENTER
He had a temperature of about 42 degrees Celsius in the center and was seen by three doctors who treated him with two cycles of a body cooling unit and applied ice packs.
Despite treatment, CFC Lee’s temperature remained at 42 degrees Celsius and when he began to foam at the mouth, he was evacuated to Changi General Hospital.
He arrived around 9.50 a.m. M. With a temperature of 41.6 degrees Celsius. He was intubated and treated with two pints of iced intravenous drip, but was found to have organ damage from heatstroke.
He was transferred to the Intensive Care Unit, but his condition continued to deteriorate, and he later showed brain dysfunctions and his prognosis was later considered terminal and irreversible with probable brain damage.
He was pronounced dead on April 30, a few weeks after the march, and the cause of death was multiple organ failure due to heat stroke. Police said in their report read in court that they do not suspect foul play in CFC Lee’s death.
The delay in his evacuation was a contributing factor to his death, police said.
After the incident, six SAF servicemen were fined by a military court for the case. CPT Tan was charged in state courts in October 2018 with causing the death of CFC Lee through a reckless act that does not amount to wrongful death.
READ: SAF captain accused of causing the death of NSF Dave Lee granted discharge without it amounting to acquittal
However, CPT Tan received a discharge that does not amount to an acquittal in early February last year. A spokesman for the Attorney General’s Office (AGC) said CPT Tan had been diagnosed with stage 4 cancer. He died a few weeks later, in February 2020, at age 31.
Medical expert Kenneth Heng from the Tan Tock Seng Hospital emergency department, who was hired to provide an independent expert opinion on the case, testified that the first aid provided to CFC Lee at the scene of the incident could have been improved.
It could have been moved to a shady area, had his shirt completely removed and ventilated to help the sweat evaporate, Dr. Heng said. He could have been given an intravenous drip, and covering him with a sheet was “counterproductive” as he would not have been able to sweat.
EXPERT EXPLAINS HEATStroke
Explaining heatstroke, Dr. Heng said that it is the most severe heat stress of all with elevated temperatures beyond 40 degrees Celsius and mental or neurological deficits.
CFC Lee had been subjected to physical exertion from fast walking and demonstrated neurological problems such as drooling, disorientation and slurred speech, Dr. Heng said.
Its elevated temperature was due to the heat produced by its muscles during the march, to which the environment, humidity and temperature contributed. It was unable to lose enough heat to keep up with its heat generation.
“Heatstroke leads to multi-organ failure,” explained Dr. Heng. “There are three main mechanisms. First, direct damage to cells due to heat, the cells of each organ are affected. Second, due to dehydration and low blood pressure, blood to organs … is also affected The bottom line is that due to cell damage, toxins are released and this causes an inflammatory cascade. Therefore, it is a vicious cycle that worsens multi-organ failure. “
Dr. Heng said the priority in heatstroke is to lower temperatures as quickly as possible. The guidelines state that it should be lowered to below 39 degrees Celsius in 30 minutes.
“There are limited things you can do on the scene, so evacuation to a medical facility with a body cooling unit should be the priority,” he said. “It took 40 minutes to evacuate (CFC Lee), which was really too long.”
He said a 10-15 minute delay would have been reasonable. He was unable to comment on CFC Lee’s “survivability in terms of retardation,” but said research has shown that if blood pressure is corrected, mortality drops from 33 percent to about 10 percent.
In response to the coroner’s questions, Dr. Heng said that there did not appear to be anything in CFC Lee’s medical records that would have predisposed him to this type of injury.
Other circumstances that could have contributed to the heatstroke include CFC Lee’s exertion the night before, as well as his reduced rest. The night before, instead of having seven hours of rest as required, CFC Lee and his fellow soldiers were punished for various infractions and forced to perform activities including bear crawling, sprints and push-ups without the knowledge or sanction of supervisors.
However, Dr. Heng said CFC Lee did not appear to be ill prior to the march and was not taking any medications. He said it is difficult to identify any precursor symptoms the condition may have identified, adding that the cramp CFC Lee suffered from was quite nonspecific.
The coroner said he would consider the evidence and deliver his findings on January 27.
FURTHER STEPS TO IMPROVE HEAT INJURY MANAGEMENT
In the wake of CFC Lee’s death, an Investigative Committee was convened to investigate the incident and several recommendations were made to minimize recurrences.
These include reinforcing the management of heat injuries, emphasizing to commanders the need to adhere to regulations and guidelines, and strengthening the evacuation decision-making process.
An external review panel commissioned by the Ministry of Defense in May 2018 found that SAF’s heat management measures were generally robust and in line with prevailing industry practices.
READ: Death of NSF Dave Lee: SAF to improve prevention, management of heat injuries after review
The panel suggested several additional measures, such as adjusting the work and rest cycle, improving awareness of heat injuries, and addressing impediments to self-assessment that could discourage soldiers from speaking up when they feel unwell.
The panel also emphasized that early recognition of heat injuries was the most important of its recommendations, saying they all have a key role to play in recognizing signs and symptoms in fellow soldiers.
First aid must be given and victims evacuated as soon as possible, and commanders and medics must err on the side of caution, as the degree of heat injury is difficult to determine with precision. When in doubt, all suspected heat injury cases should be transferred to a medical facility, the panel said.
