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Background and statistics
A media outlet shares a report about an unnatural death in Thimphu raising public concern and debates. The probable cause of death is yet to be ascertained since it has not been unveiled by death investigators. Yet, the readers assume it to be hypothermia, prophesying the same as declared by the investigators in initial cases. Some readers are reluctant to accept the tribulation. The veracity is, hypothermia can be fatal, especially during these hours in a cold environment like Thimphu, with concentrated cold-susceptible inhabitants.
In Thimphu, over the past 30 days (December 12th, 2023 – January 10th, 2024), the forensic medicine department at Jigme Dorji Wangchuck National Referral Hospital, in collaboration with the police, has investigated a total of five unnatural deaths, with three being attributed to alcohol intoxication and exposure to cold temperatures. Of the three unnatural deaths investigated, two were found outdoors, and one occurred at home. Over those 30 days, the average low temperature recorded in the Khushuchen area of Thimphu was 4.7 degrees Celsius, and the high was 5.1 degrees Celsius. Additionally, the average low temperature recorded in the Babesa area of Thimphu was -2.3 degrees Celsius, and the high was 15.1 degrees Celsius (Source: NCHM report).
Over the last three years in Thimphu, there have been reported cases of mortality related to alcohol and hypothermia. In 2023, among the 51 recorded unnatural deaths at the Forensic medicine department, three were attributed to hypothermia and alcohol intoxication. In the preceding year, 2022, there were 43 reported unnatural deaths, with one linked to alcohol intoxication. In 2021, 35 unnatural deaths were reported, with one case associated with alcohol intoxication.
Hypothermia
The German physician Carl Reinhold August Wunderlich studied one million readings and calculated the average mean. He inculcated the idea that a normal body temperature of the human body is 98.6 degrees Fahrenheit (37 degrees Celsius). So, basically, when the body temperature drops below the normal range, it is termed as hypothermia, but it is not considered significant until it reaches a certain point. The severity of hypothermia is categorised into mild hypothermia (32 to 34.9 degrees Celsius), moderate hypothermia (28 to 31.9 degrees Celsius), and severe hypothermia (below 28 degrees Celsius), (Grushka, 2024)
General Risk Factor
Winter in Thimphu, and other mountainous regions, is characterised by cold air temperatures, especially after sunset, posing a significant threat to vulnerable individuals such as the elderly, infants, emaciated young adults, and individuals with comorbidities like hypothyroidism or malnourishment. Moreover, external factors, including inadequate heating systems at home, insufficient protective clothing, inaccessibility to good-quality food, and prolonged exposure to cold temperatures while incapacitated by alcohol or drug use in chilly surroundings, contribute to the risk of developing hypothermia.
Forensic Aspect of Investigation
Death investigators confirm the alcohol content in the deceased’s body through blood or urine analysis, and they determine hypothermia through the presence of clinical features and analysis of blood in the left and right part of the heart. The reliable marker for alcohol is objective, while hypothermia is both subjective and partly objective. The temperature of the body, measured after death, cannot confirm that the person died from hypothermia. Every death discovered in a frozen state cannot be assumed as death from hypothermia. Some unnatural disease or other traumatic cause might have led to the person’s death, and the body might have frozen after death. This is entirely challenging, and it is the work of a forensic pathologist to find out the cause of death. If both natural and traumatic causes are ruled out, the cause of death is then narrowed down. The detection of a higher concentration of alcohol in the deceased’s blood suggests that the individual’s capacity for thermal regulation behaviour was likely compromised. This impairment, coupled with exposure to cold temperatures, could lead to the person’s death.
Forensic aspect of hypothermia and Alcohol intoxication.
When a person is exposed to an air temperature below 10 degrees Celsius, it can lead to hypothermia, which is further worsened when amassed by cold wind and wet clothing. If the core body temperature drops below 32-24 degrees Celsius, it can result in decreased levels of consciousness, heart rate, respiration rate, and blood pressure. Without immediate regulation of body temperature, recovery is unlikely after one hour, and the person may succumb to hypothermia (Saukko & Knight, 2016)
On the other hand, alcohol’s vasodilatory effects increase blood flow to the periphery, intensifying heat loss when exposed to cold. People believe the myth that alcohol warms up the body and keeps the body warm in a cold environment. The warming of the body is due to vasodilation and increased blood flow to the peripheries, but the effect is only for a short duration. Instead, the warm body cools very fast.
Higher blood alcohol concentration (BAC) can also suppress the thermoregulatory centre in hypothalamus, impairing thermoregulation and subsequently leading to hypothermia. A BAC level of 350 mg/100 ml of blood will comatose a person, and sometimes death follows immediately due to suppression of the cardiorespiratory centre. A blood alcohol concentration (BAC) of 30-50 mg/100 ml of blood will cause disorientation and an inability to drive, leading to road crashes and potentially death from severe head injuries or hypothermia if the individual is trapped in cold temperature. A blood alcohol concentration of 150-200 mg/100 ml of blood shows obvious signs of drunkenness, lowering the person’s ability to move, which may result in them lying on the side of the road and dying from hypothermia. While unconscious in a cold environment, the body loses heat to the surroundings until it reaches equilibrium. Typically, within one hour, if the body temperature drops below 32 degrees Celsius, the person may succumb to hypothermia (Saukko & Knight, 2016)
Death Incidents from Hypothermia and alcohol intoxication in Thimphu.
To mitigate death from combination of alcohol and hypothermia, practising responsible drinking and adopting effective thermoregulation behaviours are crucial. If someone is consuming alcohol in a social gathering or at a restaurant especially during night hours, the caregiver should ensure they are accompanied until they safely reach home. There have been cases where individuals who have consumed excessive alcohol end up falling asleep in their vehicle, either out of fear of entering their house at an unconventional hour or comatose due to a high concentration of alcohol in their blood. Unfortunately, by the time they are discovered, they are often found frozen, even within the confines of a closed vehicle.
Instances have been observed where a group of individuals indulged in both alcohol and drugs at an outdoor camp. While most were heavily dosed, some wisely wrapped themselves in blankets before sleeping, whereas one individual lying even beside the fire succumbed to hypothermia. Both alcohol and narcotic drugs act as respiratory depressors, causing individuals to lose consciousness beside the campfire. Unfortunately, the fire itself eventually dies out as they are unable to add wood. Setting up camp in an open area, especially in winter, is highly unsafe unless accompanied by a sober individual.
It is crucial for individuals stepping out in cold temperatures to wear thermal clothing that covers the entire body. The ideal attire is one that possesses the ability to effectively trap the body’s generated heat, with an outer layer that resists water and cold. While cotton clothing is effective in retaining heat when dry, it absorbs sweat during prolonged walks, leading to wet clothes that can ultimately cool the body and subsequently develop hypothermia. Tragic incidents have occurred in the Thimphu region, particularly involving children who, while fleeing high-altitude areas at night, traverse through forests and succumb halfway due to insufficiently insulated clothing. As they pass through cold temperatures, they also lose body heat very fast. The brain in a hypothermic state causes confusion and physical exhaustion, and the individual may end up lying on the ground.
In cases involving individuals with mental illnesses (schizophrenia, dementia), vigilant supervision by caregivers is crucial. There were Incidents in Thimphu, where such patients have managed to escape from their homes, ascending to higher altitudes, and unfortunately succumbing to hypothermia. Shockingly, these individuals were discovered unclothed in the elevated areas, initially prompting suspicion of foul play in their deaths. However, from a forensic perspective, these cases are interpreted as instances of paradoxical undressing, and death was confirmed with prominent features of hypothermia.
Paradoxical undressing is exhibited, mostly in the final stage of hypothermia, where despite the cold surrounding temperature, the person feels warm and removes clothing. Another behaviour is known as ‘terminal burrowing’, a self-protective behaviour where individuals will hide in deep corner spaces, such as cupboards, burrowing under many layers of clothes, or sometimes under soil. They are found dead in unusual places, and usually, these scenes appear disturbed and disoriented, often raising suspicions.
Few individuals have chosen to disconnect from their families and lives on the corners of the Thimphu streets. It’s possible that they were abandoned by relatives who had relinquished hope because they were found to be addicted to alcohol and some with mental health problems. Accustomed to a life of self-reliance, some of these individuals have tragically been found dead due to hypothermia. Upon inspecting their living conditions, it becomes evident that they lack a warm shelter and proper clothing, not to mention access to adequate food. Instead, the scene reveals empty bottles of alcohol, with witnesses attesting to seeing them in an inebriated state consistently.
Travellers have encountered incidents where vehicle accidents led to severe bone injuries, leaving them immobile. Tragically, some succumbed to hypothermia in these situations. While it may be challenging to definitively attribute the cause of death, signs of hypothermia often indicate its contribution. The safest course of action is to avoid travelling at night, especially in winter, particularly through high-altitude routes, to mitigate the risks associated with both accidents and exposure to extreme cold.
Older people and emaciated young adults.
Older people are at risk of developing hypothermia, if proper thermoregulation is not initiated externally by caregivers. You may be hearing elders at home complaining of feeling cold despite thick cloth and maintaining warm room temperature. This is because the body’s mechanism to respond to cold diminishes as we age. Additional factors like, decreased muscle and fat mass, impaired cognitive functions, limited mobility causes them to develop hypothermia. Impaired circulation, which reduces the blood flow to the extremities in deed causes cold extremities, which they often complain of cold feet despite wearing socks also. The good advice would be to wear thermal clothing, do mild physical exercise, provide a warm room and avoid going out in cold weather.
Thin and undernourished young adults may struggle with regulating their body temperature due to a lack of sufficient muscle mass for heat production and an inadequate layer of fat for heat retention. Consequently, the generation of heat is reduced, while heat loss is heightened. To prevent this, ensure they wear layered clothing, use insulated outerwear, and warm accessories. Encourage a balanced diet, regular indoor physical activity, and staying dry. Keep indoor spaces warm, monitor health regularly, and educate them on recognizing early signs of hypothermia.
How to Prevent Hypothermia?
Our body naturally regulates its temperature in response to stimuli of external surrounding temperature. The body temperature remains in normal range when the heat produced in the body equilibrium to the heat host. If the surrounding temperature is high, the body regulates thermoregulation by parasympathetic response which is initiating increased respiration rate, vasodilatation, and sweating. However, in extreme conditions, internal temperature regulation may not be sufficient, necessitating the initiation of external thermoregulation behaviours. In the context of preventing hypothermia, there are two primary methods.
Enhance Heat Production.
Heat is generated and retained in the body through a process called thermogenesis. When the surrounding temperature goes down, the body regulates temperature by sympathetic response, which is vasoconstriction, involuntary muscle contraction manifested as shivering, and release of thyroid hormone to regulate metabolism.
Rather than drinking hot green tea or water and letting the body consume stored glucose, eating a good diet has weightage. Moreover green tea is a vasodilator (Kaitlyn E. Redford and et al., 2021) and it is advisable to drink when you wish to cool your body. A protein rich diet undergoes metabolism; converting food into energy, generating heat during the process and increasing body temperature. Individuals with low muscle mass or emaciation may need regular meals to initiate metabolism and generate heat, as they have less stored energy.
Muscle contraction, requiring ATP energy, contributes to heat production during the oxidation of glucose. Lack of external body movement may trigger shivering, causing muscle contraction and heat generation. Engaging in physical exercise, even in a controlled room temperature, can effectively generate heat from muscle contraction and prevents hypothermia.
Preventing Heat Loss.
Heat loss from the body occurs through conduction, convection, radiation and evaporation. Initiating thermoregulation behaviours to mitigate these factors is essential for preventing heat loss.
Avoid contacting objects colder than body temperature, as the contact pertains to conduct heat from hot to cold medium. Warm clothing, blankets, and mattresses before use or utilize electric alternatives. Minimize exposure to cold air by maintaining an airtight house and avoiding the use of cold water. Ambient room temperature of 18°C is suitable for healthy individuals, 16°C for those with respiratory problems, and 20°C for the disabled, elderly, sick, and young (WHO, 2018). Wear thermal clothes with water-resistant layer materials, especially during outdoor activities. Covering an infant’s head is crucial as a significant amount of heat is lost from the head. Be mindful of sweating during exercise in cold environments, as it leads to heat loss.
How to manage an individual suffering from hypothermia?
A rapid and well-executed response involving the following measures can significantly mitigate the direct consequences of hypothermia.
- Bystanders bear the responsibility to assist intoxicated individuals in cold environments. They may be found on either side of the road or in cold rooms. Early intervention can make a significant difference in preventing fatalities caused by alcohol and hypothermia.
- Seek Professional Medical Attention without delay. Hypothermic death can be prevented if managed without delaying, as health professionals are well trained.
- Transfer to Warm Environment: Move the affected individual to a warm indoor or sheltered space to minimise cold exposure and prevent further heat loss.
- Clothing; promptly remove soaked clothing to halt additional heat loss.
- Core Warming: Emphasise warming critical areas like the chest, neck, head, and groin. Use resources like electric blankets or skin-to-skin contact under dry layers.
- Avoid drinking alcohol and Betel nuts during the recovery time. These are vasodilators and will cause heat loss.
- CPR; Initiate CPR if the individual appears lifeless. By now all the people must know how to do basic resuscitation. Early initiation of resuscitation can save the life of individuals.
It is clear from the above incidents that hypothermia alone has not caused the person’s death. Factors such as inadequate clothing, alcohol and drug intoxication, mentally ill patients, neglected individuals with poor self-care, and travelling through higher altitudes at night are potential contributors to incapacitating a person and leading to death from hypothermia. Hypothermic deaths are mostly accidental in nature, and human beings have the capacity to prevent them unless thermoregulatory behaviour is incapacitated. Although the figure is not very high, it is significant when compared to the population size of a place like Bhutan, where the nature of death is preventable.
Written by;
Chencho Dorji
Forensic nurse, Medical Death investigator.
Edited by;
Dr. Dawa Zangpo
Forensic specialist, Medical Death investigator.
