Lightning strikes literally have an incidence of about 1 in a million. Early last year two people in the same small rural Australian town were hit by lightning in the same storm – and that town was where I work (perhaps I should’ve bought a lottery ticket that day).

Amongst other things, I work in a rural GP practice in New South Wales, Australia. It was lunch time. A beautiful summers day. I was looking out over the town when a storm started to roll in.

If you were a 7 year old child drawing a picture of the storm on a sunny day, it would look like this storm. A single grey angry cloud frantically firing out bolts of lightning in an otherwise perfectly blue sky.

I was out for a walk with my boss – the GP supervisor at my practice. We do ‘walking tutorials’ every week. The cloud headed right over us and a loud flash-bang briefly made it difficult for me to control my bodily functions. I was scared. We hastily decided we should head back to work as we didn’t want to get zapped.

When we got back to the surgery there was a patient waiting to be seen. He had been hit by lightning…

Patient Number One

A 70 year man presented with left sided facial droop and mildly slurred speech. He described how he was loading his pick-up truck with firewood when the storm came over. He saw the bolt of lightning hit the truck and a small branch of lightning shot off and hit him in the leg.

He had left sided facial droop and slurred speech. He wasn’t quite sure if this was a new thing or not.

Otherwise he was well. The rest of his neurological examination was normal.

I admitted to him I had never seen a lightning strike before, and together, the patient and I read up about lightning strike injuries on Life In The Fast Lane.

It seems that lightning strikes can cause almost any sort of injury. Often it causes death. He was lucky. It seems that his car caught the brunt of it, and he only got a small side bolt.

Most commonly it causes skin burns, but can also result in cardiac arrhythmia and neurological signs. It had entered him in his leg, and there was no sign of any burn or other injury.

Luckily (for him), neurological signs are often transient and resolve by themselves. But I wasn’t willing to take a risk, and I sent him to the emergency department.

He had some unremarkable blood tests and a normal CT and was observed overnight. His symptoms resolved and he was discharged home.

Patient Number Two

Having just sent Mr. Lightning Strike Injury to hospital (“Wow, I’ll never see one of those again!”),  I was sitting down to to have some lunch, when another doctor at the practice asked for some assistance with an unwell patient.

A 74 year old lady was lying on the bed in the treatment room, looking pale. She was conscious but not making much sense. She had come to the practice with palpitations and dizziness approximately 1 hour after being struck by a bolt of lightning. She had been standing in her kitchen with the door open, when the lightning struck the door and reflected off and hit her in the chest, knocking her off her feet and flinging her several metres across the room.

An ECG showed acute atrial fibrillation, with a very fast rate (up to about 180). Her BP was fluctuating but was at one point as low as 80 mmHg (systolic).

I have cardioverted plenty of patients in the past in the Emergency Department, but being out in the middle of nowhere, with nothing but a cannula and an AED (automated external defibrillator) was nerve-wracking. In the emergency department, I would have access to a proper defibrillator (with the ability to synchronise a shock and recognise rhythms) and placed the pads on, with the expectation that if or when she lost consciousness I would give her a DC cardioversion.

With my AED I didn’t really have that option. I stuck the pads on just in case, but I suspect it would have advised a ‘non-shockable rhythm’ and not done anything if I had tried to use it.

The nurse got IV access and we gave her 1L of fluid, 10mml IV magnesium, metoprolol and called an ambulance! It seemed to take forever to get there. Once the ambulance arrived, we attached a proper defibrillator, but by this time her BP was improving and her heart rate was settling to around 150. Had she not improved, I would have considered delivering a shock (based on her conscious level – if unconscious – shock!), but without the correct resuscitation equipment this would not be advisable.

In the emergency department she received rate control treatment and was discharged, and she reverted overnight at home. The following day she attended hospital for planned DC cardioversion, where is was confirmed that she was back in sinus rhythm.

Since that day she has had several other episodes of self-limited atrial fibrillation.

It seems as though cardiac arrhythmias are a well recognised consequence of lightning strike. They are often self-limiting, but in the very acute situation they can be fatal!

All of this inspired me to write an article about lightning injuries – so if you want to learn more about how to examine and treat lightning strike patients, head over the almostadoctor encyclopaedia lightning strikes article.