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.

Day One Rhabdo Facilitated Learning Analysis – Rogue River-Siskiyou National Forest 9

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