FOLLOWING SEVERAL cerebrovascular strokes, an elderly man was placed in a nursing home for long-term care because of his immobility and paresis. Regular sessions in a heated whirlpool were part of his therapeutic regimen. One day, shortly after being placed in the whirlpool, he moaned and thrashed. He was promptly removed from the whirlpool and noted to have erythematous skin extending from the nipples to the feet. The on-call physician was notified and observed blistered and erythematous skin. Treatment consisted of burn wound management, and death occurred several days later from burn wound sepsis.