InvestigatingCases of Rhabdomyolysis

Following a March, 2002

New York Police Academy Training Course

(Presented by Caroline Bragdon, MPH:

PHPS Grand Rounds, 9/30/2002)

New York City Department of Health & Mental Hygiene

Investigation conducted by:

Caroline Bragdon, MPH (PHPS assignee with NYC DOHMHs Environmental & Occupational Disease Epi Unit)

Nancy Jeffery, RN, MPH (former director of EODE Unit)

Presentation Objectives

Describe the steps of my investigation Outline difficulties in conducting

investigations across agencies Share lessons learned about

rhabdomyolysis Demonstrate time & resource

commitment required

EODE’s Mission

“To investigate and prevent environmental and occupational disease among residents and workers in NYC.”

EODE activities thus include: $ Investigating cases and potential clusters of

environmental and occupational disease; $ Researching background information on environmental

and occupational exposures and diseases; $ Providing technical assistance to City agencies,

employers, unions, community organizations and others on health effects of environmental and occupational exposures.

Background of Investigation: Early March 2002 On 3/19/02 the NYPD requested the DOHMH

to consult on a series of hospitalizations following a Plainclothes Training Course

The training course was conducted from 3/13 – 3/15/02 at the Police Academy in the Murray Hill neighborhood of Manhattan

Summary of “Outbreak”

Total of 28 officers & sergeants participated in the 3-day training course

10 out of 28 were hospitalized between 3/15-3/19 for rhabdomyolysis

Up to 11 more reported having elevated creatine kinase (CK) levels following the training

What is Rhabdomyolysis?

Breakdown of muscle fibers with leakage of potentially toxic cellular contents into the systemic circulation

Subtle clinical presentation diagnosed with serum creatine kinase (CK) elevations in excess of 2-3 times the reference range

Reasons for Concern

Rhabdomyolysis can lead to more serious complications including renal insufficiency, acute renal failure, hepatic insufficiency, cardiac arrest and compartment syndromes

In 1988 a MA police trainee & a FDNY trainee died of complications of rhabdomyolysis following two separate agency trainings

Background Information

NYPD’s Supervising Chief Surgeon had concluded that based on the available information, the elevated CK levels were probably due to the physical activity involved in the training course

Director of the NYPD Occupational Safety and Health Unit requested additional investigation by DOHMH

Gathering Relevant Information: Early March 20021) Literature Review:• Exertional Rhabdomyolysis and Acute Renal Impairment – New York

City and Massachusetts, 1988. MMWR 1990; 39(42); 751-756• Hyperthermia and Dehydration-Related Deaths Associated with

Intentional Rapid Weight Loss in Three Collegiate Wrestlers — North Carolina, Wisconsin, and Michigan, November–December 1997. MMWR 1998; 47(6); 105-108

• Craig, S, Kreplick, LW. Rhabdomyolysis. eMedicine Journal, January 18 2002, Volume 3, Number 1

• Gabow PA, Kaehny WD, Kelleher SP. The Spectrum of Rhabdomyolysis. Medicine (Baltimore) 1982 May;61(3):141-52

• Line RL, Rust GS. Acute Exertional Rhabdomyolysis. American Family Physician 1995 Aug;52(2):502-6

• Sauret JM, Marinides G, Wang GK. Rhabdomyolysis. American Family Physician 2002 March 1;65(5):907-12

Gathering Relevant Information: Early March 20022) Phone Interviews with experts:• Michael Pratt, MD, MPH: Physical Activity and Health

Branch, Division of Nutrition & Physical Activity, CDC• Michael Kennedy, MD: former EIS Officer who

investigated 1988 FDNY & MA Police Trainee cases• Rich Killingsworth, MD: UNC, Chapel Hill, EIS Officer

who investigated 1998 deaths among wrestlers• Edward Zambraski, Ph.D: Rutgers University

Hydration and Rhabdo Expert• Bruce Wenger, MD: US Army Performance Lab

Exertional Heat Stroke Expert

Findings: Risk Factors for Rhabdomyolysis Inherited/genetic & metabolic disorders Toxic (alcohol, drugs, other toxins) Excessive muscle exercise Direct muscle injury (compression, trauma) Ischemic injury (vascular occlusion) Viral & Bacterial Infections Heat related syndromes Eating certain kinds of fish (eel, pike, buffalo)

Most common risk factors for Rhabdomyolysis Exertional & heat stroke (untrained

people undertaking vigorous exercise) Crush injury & trauma (ischaemia, direct

muscle injury) Alcoholism Drugs (both legal & illegal)

Drugs associated with Rhabdo

Legal: diuretics, antihistamines, AZT, antidepressants, cholesterol-lowering & corticosteroids

Illegal: cocaine, heroin, LSD, amphetamines, MDMA, ecstasy

Findings from Phone Interviews

Rhabdo is seen frequently among military recruits following short intense & hard endurance exercise

Temp of room, common illness, caffeine consumption, over-the-counter supplements, drugs & alcohol, physical fitness, hydration, diet, and possible crush injury should be assessed in interview with trainees

Ideally training should be recreated with CK levels monitored throughout

Review of Training Curriculum:Late March 2002 3/26/02 met with Director of the Occupational Safety

and Health Unit & trainers who taught the 3/13-15 training course

Conducted walk through of the rooms used for training with DOHMH Industrial Hygienist

Watched demonstrations of exercises Reviewed training curriculum Discussed 3/13-3/15 Plainclothes Training Course

with trainers for their impression of events

Findings from Police Academy Meeting Environmental conditions in training rooms

was appropriate (CO, temperature) Officers/Sergeants report enjoying training

curriculum Performance in training does not impact

future employment Physical activity on 2 out of 3 days only Training exercises did not appear to be

strenuous aerobically, however, kicking, punching, falling and cuffing was involved

Description of Training Participants Majority of training participants were from

the 6th precinct in Greenwich Village (prostitution/anti-crime)

Participants were seasoned officers with many years on the force

No physical activity requirement at NYPD, many unused to exercise

Many officers typically worked night shift

Related to WTC?

Heightened awareness of health status of NYPD following 9/11

First training conducted since training was suspended following 9/11

NYPD may have been working increased hours, atypical shifts, & engaged in unfamiliar activities

Next Steps: Early April 2002

Develop questionnaire for trainees Develop medical chart abstraction form Meet with NYPD Supervising Chief

Surgeon Discuss plans with Unions (PBA & SBA) Gain input/approval for questionnaire

from DOHMH, NYPD & Unions

Questionnaire Development15 Page Questionnaire assessing:

Physical Fitness & Exercise Habits Underlying Medical Conditions Hydration/Diet pre/post & during course Activities pre/post & during course Drug & Alcohol Behavior Prescription drug medication Recent viral/bacterial illness

Barriers to Investigation: Why the Questionnaire was dropped SBA/PBA & NYPD all resistant to questions

that would indicate culpability Drug/alcohol & certain infectious disease

questions likely left blank Desire to collaborate with unions/NYPD

conflicted with need to conduct science-based investigation

Bottom Line: Recommendations were likely to be the same regardless of findings

Medical Chart Abstraction Form

No standard in existence: thus borrowed outline from injury surveillance abstraction form for workers at WTC site

Collaboration with Integrated Surveillance team to fine-tune form

Multiple drafts reviewed by staff from both agencies, physicians & nurses prior to pilot test & implementation

Next Steps: April 2002

Medical Chart Review with Integrated Surveillance Staff

10 Charts, 5 hospitals, 3 counties 8 charts in 3 NYC hospitals 2 charts outside city jurisdiction

Medical Chart Review Findings: Summary of Ten Hospitalized Age range 33 – 43 years old, average

age of 36 years 8 male, 2 female 5 smokers 8 prostitution/anti-crime cops from 6th

precinct (all male) All walk-in, 2 on 3/15, 1 on 3/16 and

remaining 7 on 3/18-3/19

Medical Chart Review Findings

CK levels 4,390 - 118,882 units per liter (normal: 60 – 200 units per liter)

Primary diagnoses: rhabdomyolysis Secondary diagnosis: diffuse myalgias;

disorders of muscle, ligament or fascia; or, tendonitis, myositis, and bursitis

6 had dark or tea colored urine No tox screens but negative history White blood cell counts were within acceptable

ranges

Medical Chart Review Findings

5 hospitalized < 1 day 5 hospitalized 4-10 days Of those hospitalized > 1 day: 2 had

underlying conditions unrelated to the training which required follow-up and hospital care

All received IV fluids, responded well to treatment, decreased CK levels over time

Findings of interest

All 10 indicated that the activity preceding the onset of their chief complaint was a rigorous or strenuous training exercise at the police academy

8 also reported being told by their Commanding Officer to report to hospital after learning that other officers from the training had been hospitalized

Conclusions

Difficult to conclude whether training differed in any significant way from previous trainings

Previous trainings may have caused elevated CK levels and muscle soreness among trainees who may not have interpreted their symptoms as being severe enough to merit medical attention

CO’s orders may have revealed elevated CK levels that had always occurred following training exercises at the police academy

Further Conclusions

Those unaccustomed to strenuous physical exercise are specifically vulnerable to rhabdomyolysis

No physical activity requirement at NYPD & activity declines with age

Smoking, Overweight, Diabetes, Hypertension revealed in charts

Final Steps: May 2002

Final Meeting with NYPD on May 7 Preliminary summary of chart review

findings (7 completed) Written report with recommendations

sufficient to re-institute the Plainclothes training course at the Police Academy

Discussion of ways to avoid future cases (diplomatic recommendations)

Recommendations1. Provide info packets prior to training2. Urge candidates to avoid beverages that act as

diuretics (caffeine/alcohol) & drug use 24-hours prior to the training

3. Re-schedule training in the event of a viral or bacterial illness

4. Require medical clearance for those with underlying chronic conditions

5. Monitor the ambient environment of rooms 6. Maintain adequate hydration by providing water

and hydration beverages7. Remind officers of the need to maintain physical

fitness by engaging in regular physical activity

Final Timeline

Training: March 13 –15 Hospitalizations: March 15 – 19 Info Gathering: March 19 – 25 Tool Development: March 25 – April 18 Chart Review: April 18 – May 18 Final Meeting with NYPD: May 7 Summary Report: Completed in June Final Report: Approval still pending

Inter-agency Lessons Learned

Vocabulary, culture, concerns & objectives different between NYPD, Unions & DOHMH

Changes in administration a hindrance Each agency has its own review

process & hierarchy which takes time Collaboration means that you must

compromise, but that is OK

Final Summary

Report writing, review & finalization process took longer than investigation itself

Significant staff time & resources dedicated to investigation

Heightened awareness following 9/11 may be a drain on agency resources (other examples include school rashes, postal worker deaths)

Good working relationship established with NYPD