day one rhabdomyolysis facilitated learning analysis
TRANSCRIPT
Day One Rhabdo Facilitated Learning Analysis – Rogue River-Siskiyou National Forest 1
Day One Rhabdomyolysis
Facilitated Learning Analysis
Rogue River-Siskiyou National Forest
May 2016
Day One Rhabdo Facilitated Learning Analysis – Rogue River-Siskiyou National Forest 2
Contents
1. Summary………………..……………..…….… 3
2. Narrative………………………………………. 3
3. Crew Lessons…………………………….…..... 8
4. Rhabdo – What We Know and Don’t Know….. 8
5. The “Gray Area”………………….…………… 9
6. FLA Team……………………………………...11
Finishing the 110-Pound Pack Test.
Day One Rhabdo Facilitated Learning Analysis – Rogue River-Siskiyou National Forest 3
1. Summary
Jay was hired to be a rappeller for the 2016 field season. Rappelling out of hovering helicopters to initial attack
remote forest fires is extremely arduous work with little room for error.
On Monday May 2, 2016—Jay’s first day—he completed the rappeller fitness testing (pull-ups, push-ups, sit-
ups and 1.5 mile run), the Work Capacity Fitness Test, one additional 1.7 mile run, as well as a 110-pound Pack
Test in the morning.
As early as 1200 hours, Jay started experiencing leg cramps. On a 6-mile run with the crew in the afternoon,
EMTs noticed Jay’s pale, hot, dry skin and stopped him to evaluate. Based on their evaluation, Jay was removed
from the training and taken to a hospital where he was eventually diagnosed with Rhabdomyolysis.
2. Narrative
Jay was nervous. He really wanted to be here, he really wanted to work on this crew. He had trained hard in
addition to working full time at a Christmas tree farm. He knew he was capable of this; he was a Marine.
Even so, he was still worried. Three weeks prior to his start date, his “numbers” (for pull-ups, push-ups, sit ups,
and run pace) had started to drop off. Jay wondered if he had peaked too early. He tried to “taper” and even took
the last week off before starting with the crew.
Jay knew Day One would be tough. In fact, he knew very well what Day One would look like. Like all the other
new hires, Jay had visited the base to express his interest in the crew and gotten a tour that included a specific
description of what Day One would consist of.
Day One is tough. The entire training for new hires is tough, because the job is tough—and that is exactly why
Jay wanted to work here. Knowing all this is what made him worry about his recent drop in numbers. But here
it was, the chance to do exactly what he wanted to.
0800
Pull-ups Jay dropped off the bar. He was furious—and so disappointed. He’d eked out half of what he’d peaked at. This
first showing was not helping his mental state. The push-ups and sit-ups were also discouraging. The 1.5 mile
run took him a minute longer than normal. At least the 45-pound Pack Test went fine, a bit of a rest really. Next,
the run back to the base was OK, not painful.
45-Pound Pack Test. 1.7 Mile Run.
Day One Rhabdo Facilitated Learning Analysis – Rogue River-Siskiyou National Forest 4
“As a rappeller, if we only trained to the 45-pound
Pack Test, we could never safely engage a fire.”
0945
110-Pound Pack Test
Now it was time for the heavy pack—110 pounds for 3 miles. All the first-time crewmembers were instructed to
build their packs to 110 pounds using the various items lying about. Jay was the first to finish packing his bag.
In the confusion of getting everyone ready, somehow his packed didn’t get checked by the trainers.
Off they went.
Not long into the hike, Jay dropped his pack because he knew something wasn’t right. The trainers immediately
brought out a scale and realized his pack was overloaded at 140 pounds. They removed the extra weight and got
Jay moving again. He completed the test with no further troubles.
1130
Jay is Shaky Jay was shaky during gear issue time. He ate some snacks, hydrated, and tried to relax a bit.
1230
Leg Cramp Jay experienced a leg cramp during leg lifts. During another pull-up session, the leg cramp returned and caused
him to drop off the bar. One of the trainers massaged his leg to help alleviate the cramp.
During the lunch break, Jay described his feeling to another first-time crewmember. The other crewmember
said it sounded to him like Jay’s body was “one big cramp.”
Crew leadership made a point to visit with Jay about how he was feeling. Jay, of course, wanted to keep going.
The overhead understood that. They instructed that they really needed him to speak up if things worsened or if
there was an injury.
Crew EMTs met separately and agreed to keep a close eye on Jay.
Loading Gear for the 110-Pound Pack Test. The 110-Pound Pack Test.
Day One Rhabdo Facilitated Learning Analysis – Rogue River-Siskiyou National Forest 5
Jay said he would pass out before he quit.
1300
Paperwork The crew began filling out paperwork and covered Standard Operating Procedures.
1440
The 6 Mile “Overpass Run” The crew started the “Overpass Run”—approximately 6 miles involving the entire crew (both new and
returning crewmembers). One of the trainers, an Advanced EMT (AEMT) ran with Jay for the first mile to
continue evaluating him. “I asked him if he had ever quit anything,” says the AEMT. “I knew about his military
time and how highly motivated he was. This was a mental check as well as a way to see if he would push
himself further than he should. He said he would pass out before he quit. I reiterated the need to pace himself
and to go as slow as he needed to.”
Two miles in, Jay got a status check from the “Mobile EMT” who was in a roving vehicle, a Chevrolet
Suburban. Jay made it to the halfway mark and turned around to head back. The AEMT who was running along
with the group—moving back and forth between the lead pack and those in the back—looked over Jay and
discussed what he saw with the roving EMT.
“I noticed a lack of perspiration on Jay’s shirt,” says the AEMT. “We both acknowledged the cloud cover and
dropping air temperature, probably in the 60s.”
By mile four, Jay was visibly pale. The trainers stopped him for a check. “Jay was shaky and wavering while
walking. We guided him about 100 yards to the Suburban,” says the AEMT, who then had a discussion with
another trainer. The AEMT pointed out Jay’s lack of
sweat and said they should “cut it”—meaning end the
run for Jay and put him into the Suburban.
Meanwhile, the roving EMT was giving Jay an “alert
and oriented” quiz. Jay correctly stated the date, time
and our current president, but then miscalculated a
simple math problem. “We all concluded the run was
over for him,” says the AEMT. Jay was reluctant to
get in the vehicle, stating: “I can still walk back.”
In the vehicle, in an effort to cool Jay down, they
turned up the A/C and placed cold water bottles in his
arm pits. The AEMT who had been running jumped
into the vehicle and they headed back to the base.
After 15 minutes in the vehicle, Jay didn’t seem to be
improving. After discussion with additional
overhead, they decided that they needed to take Jay
to the next level of care, although Jay insisted he
“just needed a shower.”
The EMTs took Jay to the base to start paperwork
and get his vitals before heading to the clinic. He had
a temperature of 104.
Initial vitals recorded by crew EMTs.
Day One Rhabdo Facilitated Learning Analysis – Rogue River-Siskiyou National Forest 6
1545
Depart for Local Medical Clinic The two EMTs and Jay departed for the local clinic.
There was a somber mood in the vehicle. Jay did not want to go to the hospital. The EMTs told Jay they needed
to get him checked out and briefly mentioned a suspicion of Rhabdo.
1555
Treatment Confusion The group arrived at the local clinic. Jay walked in under his own power. The situation was explained to the
Check-in Nurse and they provided Jay’s initial vitals. After a short wait, a nurse came out, said the doctor would
not see him, and advised that they go to a nearby hospital.
No explanation was given as to why they wouldn’t see him.
1640
More Official Confusion The group arrived at the hospital. They were unsure if they should go to the ER or Urgent Care. They chose
Urgent Care because there was no line.
As before, they worked with the Check-in Nurse and got through the paperwork. This took longer than expected
because the Check-in Nurse wanted to know if they had a workers compensation claim number.
Once Jay finally went in for treatment, the nurse came out and said that he needed to go to the ER—once again
with no explanation of why.
As Jay was brought out in a wheelchair, the hospital staff instructed the EMTs: “Don’t let him walk.”
1715
Repeat Check-In Process for Third Time They wheeled Jay across the parking lot to the ER and—for the third time—repeated the check-in process. The
waiting list was long. At this point, Jay seemed to be doing a bit better. He really just wanted a meal, a shower,
and some sleep.
The EMTs had a conversation about whether or not they should just leave. But in the event that there was an
actual problem, they decided to follow through and stay there.
1745
Jay is Thinking He’ll Be Checked and Released Jay was outside stretching when the crew EMT, who had left to get food, returned. The other crew EMT was
inside listening for Jay’s name to be called. Jay started to eat. At this point, Jay was thinking he would do a
simple check-up in the ER, get released, and be back in training the next morning.
1750
Jay is Returned to a Different Waiting Room Jay was called in. As the crew EMTs waited outside thinking Jay was in with the doctor, Jay actually had a brief
interaction with the Triage Nurse and then returned to a different part of the waiting room.
Day One Rhabdo Facilitated Learning Analysis – Rogue River-Siskiyou National Forest 7
2000
Jay Does Not Look Good As one of the EMTs was returning from the bathroom, they happened to
pass Jay in the additional waiting room. “I didn’t even recognize him. He
did not look good,” says the EMT.
They brought Jay the rest of his food and sat with him.
2200
Jay Finally Sees a Doctor Jay is finally called back in to see the doctor. After some discussion, one
of the EMTs caught a ride home.
2330
Rhabdo The EMT who stayed recalls: “Jay came out to tell me it was Rhabdo and
there were at least two more hours of tests. I gave Jay a quick brief on
Rhabdo and stressed that it was serious. I said I would make phone calls and let him know my next move.”
2345
Jay Ends Up Staying in Hospital for Eight Days After debriefing his supervisor, the EMT left the crew contact list with the Charge Nurse for Jay and went
home. He also texted Jay the overall plan, instructions on how to get into the base to get his vehicle, and a
request to touch base at 0930 the next morning with an update.
Jay ended up staying in the hospital for eight days, until his CPK levels got low enough for the doctor to feel
comfortable releasing him.
Creatine phosphokinase (CPK) is an enzyme in the body. It is found mainly in the
heart, brain, and skeletal muscle.
When the total CPK level is very high, it most often means there has been injury or
stress to muscle tissue, the heart, or the brain.
Muscle tissue injury is most likely. When a muscle is damaged, CPK leaks into the
bloodstream.
According to the
National Institutes of
Health, Rhabdomyolysis
is defined as “the
breakdown of muscle
fibers that leads to the
release of muscle fiber
contents (myoglobin)
into the bloodstream”.
Day One Rhabdo Facilitated Learning Analysis – Rogue River-Siskiyou National Forest 8
3. Crew Lessons
The Importance of Monitoring
Look for anyone struggling and monitor their condition throughout the day. The crew EMTs paid
close attention, communicated, did periodic checks, and ultimately made the call to stop, treat, and
transport Jay.
The Importance of Check-ins and Check-ups
The Lead Trainer had been making bi-weekly check-ups on Jay early on in the year but had stopped the
check-ins after he felt Jay was on track. “I heard his numbers and figured the hay was in the barn,” the
Lead Trainer explained. They will now continue with check-ins up to the start date—even if a person
seems to be “on track”.
In Your Area, What Medical Facility is Best Equipped for This?
After the “treatment confusion” of the multiple treatment center redirects, the crew emphasized that
other crews do some pre-season research and planning of where to take individuals with heat
related/Rhabdo symptoms. An Emergency Room is best equipped for this situation. Where will you go?
Know before you need to!
Trust – and Follow Through on – Your Initial Treatment Plan
The crew EMTs made the call to take Jay to the next level of care. During the long wait, Jay seemed to
improve and they debated whether or not they should just go home. They decided to follow through with
their plan even though Jay felt he didn’t need it. Your initial decision is based on something—trust it.
Reorganize Training Schedule to Reflect Day One Stress and Anxiety
Acknowledging that stress and anxiety affect physiology, there was discussion around the mental and
physical intensity of Day One. Other programs have also experienced Rhabdo cases early on in the
critical training period. One such program shifted their “hard day” from Day One to later in the week
and the occurrence of Rhabdo has sharply declined. Crew leadership is looking into how they might
reorganize the training schedule to address this issue.
4. Rhabdo – What We Know and Don’t Know
In the profession of wildland firefighting there has been a rise in the number of reported cases of
Rhabdomyolysis. This increased reporting has directly influenced an increased awareness around signs,
symptoms, treatments, and the general existence of exertional Rhabdomyolysis.
Rhabdo Key Points
New Forms of Exertion
Forms of exertion the body is not familiar with (like going from a primarily running-focused regiment
to a hiking-focused one) or familiar exertion at an intensity new to the individual, tends to cause the
type of damage and subsequent muscle fiber breakdown leading to Rhabdomyolysis.
Proper Preparation
Firefighters engage in strenuous activities and prolonged exertion, both during training and in the field.
Without properly preparing the body to perform the strenuous work, the risk of Rhabdomyolysis
increases.
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Each Case of Rhabdo is Unique
Each case of Rhabdomyolysis is unique in its causes, signs, symptoms, health consequences, and
recovery.
Long-Term Health Consequences – Including Death
If left undiagnosed or untreated, Rhabdomyolysis can become severe and lead to long-term health
consequences and potentially death.
If You Have Rhabdo Once – Will It Repeat?
There is currently no indication that previous Rhabdo cases make an individual more likely to
experience Rhabdo in the future.
Ever Felt This Type of Cramp Before?
Muscle cramps are some of the most studied and least understood reactions in the body. Cramps as a
possible sign or symptom for Rhabdo is not black and white. So far, in most cases, individuals did report
that the cramps preceding Rhabdo onset were unique—meaning they had never felt anything like it
before. The distinction of unique cramping may be helpful when evaluating a potential Rhabdo
situation: “Have you ever felt this type of cramp before?”
Time Component is Crucial
Minimizing the time between onset of symptoms and medical treatment is crucial to ensure the best
physical outcome.
Health Care Professionals Might Not Be Familiar with Rhabdo
There is variation in the level of familiarity with exertional Rhabdomyolysis among health care
professionals. In multiple cases, wildland firefighters have experienced a significant delay in the
administering of a CPK test.
Click Here for a Printable Version of a Handout for Medical Providers
Click Here For Rhabdomyolysis Awareness and Education Resources
5. The “Gray Area”
From the perspective of the crew in this
instance, the activities that day
were not excessive.
Why was Day One so demanding?
Why is it so difficult?
Is it excessive?
Multiple crews have faced all these questions. From the
perspective of the crew in this instance, the activities that day
were not excessive.
In follow-up group discussion, there was much frustration
expressed over the “friction in the system” regarding the “Gray
Area” in which they operate.
What We Prepare For “I looked at the ground and it was damn near vertical. This was gnarly country and the fire had potential. I looked my rappellers in the eye and asked: ‘You good?’ They all nodded and I put them out.
We flew back and set down. Eventually, I heard the radio traffic like everybody else: ‘The fire’s below us. I need an air tanker. We’re dropping gear to escape.’
They had to scramble out of the hole with fire on their ass—and they made it. That’s what I’m preparing folks for. I need to know
they can handle that.” – Trainer
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When Agency leadership acknowledges this
reality and works in conjunction with crew
leadership, this “Gray Area” can be reduced.
The “Gray Area” is the difference between the known demands of the job and the existing physical training
evaluation standards. These firefighters are expected to enter extremely rugged terrain, traverse the unforgiving
ground with heavy loads, fall trees, dig line, and mop-up for multiple days and then extract themselves—often
times packing out all the equipment on their backs—and then quickly prepare for the next assignment.
The ability to safely perform to that expectation again and again for months at a time is not adequately
measured by the current minimum physical training standard.
The Difference Between Reality and Policy
The true physical and mental requirement of firefighters is extremely complex. The standard to which we train
is more defined through institutional knowledge and experience. Crew leadership is tasked with ensuring that
firefighters are both physically and mentally prepared to handle ALL the rigors of the job, whether they be
typical or unexpected.
The difference between reality and policy creates a large “Gray Area” in which crew leaders must operate to
build and maintain an adequate training program. What may be perceived as “too rigorous” by some is very
different than the realities faced in day-to-day operations.
Because of this, most crew PT programs do not reflect the Arduous Pack Test, rather they reflect the specifics
their firefighters will face in a variety of terrain, conditions, and circumstances. When Agency leadership
acknowledges this reality and works in conjunction with crew leadership, this “Gray Area” can be reduced.
Until this “Gray Area” is addressed, crews will continue to do their best to determine what level of fitness
should be required for their crew based on their personal knowledge and experience. How can we support our
leaders as they are saddled with the sacred task of preparing and evaluating an individual’s mental and physical
capacity to perform and survive in this line of work?
Current Status of PT Standards
There is some acknowledgment of the “Gray Area” and the vulnerability it has created.
For the last three seasons—and continuing into this fire season—the U.S. Forest Service National Technology
and Development Program has been gathering information on Type 1 Crews to quantify the level of physical
fitness required at the elite crew level.
This data will be used to determine appropriate fitness standards with which to test individuals in these
programs. The development of the standard evaluation will be followed by the development of a fitness
program specifically designed to prepare individuals for the evaluation.
The data gathered during the 2016 fire season will be focused on Type 2 Crews to help begin to understand the
appropriate level of physical fitness required for those positions. Based on the current projections, the initial
draft of this work for the Type 1 Crews will be compiled this fall and could potentially be ready for a pilot trial
in the 2017 fire season.
Day One Rhabdo Facilitated Learning Analysis – Rogue River-Siskiyou National Forest 11
Jacqueline Buchanan
Deputy Regional Forester
Rocky Mountain Region 2
U.S. Forest Service
Jennifer Symonds, D.O.
Management Medical Officer
U.S. Forest Service
Joseph Domitrovich, Ph.D.
Exercise Physiologist
National Technology and Development Program
U.S. Forest Service
Benjamin Oakleaf
Assistant Training Manager – Boise Smokejumpers
Bureau of Land Management
Travis Dotson
Analyst – Wildland Fire Lessons Learned Center
National Park Service
6. Facilitated Learning Analysis Team