Facilitated Learning Analysis for May 2 Rhabdo injury

33% of patients diagnosed with Rhabdomyolysis develop a quick onset of kidney failure, and 8% of all cases are fatal.

The Wildland Fire Lessons Learned Center has released a Facilitated Learning Analysis for the Rhabdomyolysis injury that occurred May 2, 2016. It does not specify that it was the case that occurred on the Black Hills National Forest, but many of the facts in the document point to it being the same incident.

The short version of what preceded the injury is that on the morning of the first day of the seasonal firefighters reporting for duty this fire season, the crew was directed to complete an 8.8 mile run which they did in 96 minutes. Approximately 1/2 mile into the run one crewmember dropped out and was evaluated by a squad boss and an EMT. The crewmember and the EMT returned to the base. This was not the person later diagnosed with Rhabdo.

After the 8.8 mile run the crew jogged another 3/4 mile to a location where they ran uphill sprints and a “loop run”. From the report, after the 8.8 mile run:

Upon return to station, the remainder of the crew reconfigured and lined-out in “tool-order” to continue PT. It was noted that during this brief lull in activity, the employee who would eventually be diagnosed with Rhabdomyolysis made the comment “It’d be nice to have some water…”, to which another within ear-shot replied “yeah… I know”. The “long, slow run” was followed by three rounds of relatively short uphill sprints interrupted by a “loop-run” within sight of the hot-shot base. This event lasted roughly forty-five minutes.

Although dehydration isn’t the leading cause of Rhabdomyolysis, which is a condition caused by exertion, it can be a contributing factor.

The crewmember did not inform the supervisors that he was having discomfort and cramping, but about an hour after the work day ended he drove himself 41 miles to seek treatment at a medical facility.

At 0745 on the [next] morning of May 3rd, the hotshot superintendent was notified by the injured employee’s family that he was in the hospital with dehydration and were awaiting additional test results. He was subsequently diagnosed with Rhabdomyolysis.

The FLA points out, and this should not be news to wildland firefighters, that Rhabdo and compartment syndrome are extremely rare and difficult for a physician to diagnose.  Therefore it is imperative that wildland firefighters familiarize themselves with what can cause the condition and how to recognize the symptoms.

Not all past cases of rhabdo in wildland firefighters were correctly diagnosed during initial care. Heat illness and dehydration share common signs/symptoms and can lead to a missed diagnosis for rhabdo. In addition, rhabdomyolysis is a very rare occurrence in the general population. Many physicians will go their entire careers without seeing a single case of rhabdomyolysis. Since early detection and treatment can greatly reduce the severity and recovery time, it is important that medical providers understand and test for rhabdo.

If you are a wildland firefighter, and especially if you are a supervisor, read the entire report, make copies of the Handout for Medical Providers, and if someone exhibits the symptoms and needs treatment, accompany them to the medical facility and diplomatically talk to the physician about the possibility of Rhabdo while giving them a copy of the Handout.

In another injury involving early fire season physical training, on April 19 a wildland firefighter suffered a heat stroke on day 2 of their season. The employee was unconscious for several hours and spent four days in the hospital.

 

Author: Bill Gabbert

After working full time in wildland fire for 33 years, Bill Gabbert now writes about it from the Black Hills.

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7 thoughts on “Facilitated Learning Analysis for May 2 Rhabdo injury”

  1. I don’t treat my horses and mules, when its time to start work again after the winter off, the way they treat these Hotshots. Pretty sad.

    1. What responsibility does the employee have to come to work prepared for a physically demanding job? It’s no secret that Hotshots PT. A nine mile run isn’t that bad; I would bet that the sup informed the employee of the PT schedule when a job offer was extended.

      I would be interested to hear whether the employee asked a supervisor for water, and if the request was denied.

      The difference between FF’s and your mules is personal responsibility.

      1. This is the blame-the-injured person argument I hear too often in the Forest Service. We have a cluster of exercise-induced illness presenting during the first two weeks of training. Some of the people injured in these events have been in excellent shape. Too often I see “hell-week” mentality, and the personnel leading the exercises don’t have the training or education required to develop a hard, yet safer program. Do we really need to make rookies carry cubees up the hill all day, do 300 pullups, etc. At some point we are breaking people because we don’t know better and our “elite” status helps drive it. I’m just waiting until we kill someone.

        1. I must be missing something, because I read that they did a nine mile run followed by some hill sprints. How is that “hell week”? Did the employee speak up about the cramping? At what point does an employee have an obligation to speak up? It’s a two way street – the blame isn’t solely on the part of the administration.

          People will die. It has happened on the pack test, and that is a pretty mild evaluation. People have had heart attacks sitting in their office chairs. Sure, every effort should be made to limit death and injury, but if the standard is set so that nothing bad can ever happen we might pack up the bags and go home.

          Remember the famous quote by Dirty Harry, “A man has got to know his limitations.”

          1. What’s on the other side of the coin? Do supervisors have a duty to consider the possibility that some people might not show up in optimal shape? If it’s going to be a hot day, should the supervisors consider not starting the run at 4 pm? Maybe they should think about scheduling it earlier in the day?

            Do you think supervisors are aware that it takes a lot before some firefighters will admit they can’t keep up? Should they take that into consideration when planning activities?

            I don’t think “People will die” should be a guiding principle for leaders. Do I think people are responsible for showing up in shape? Yes. I sure don’t think we should accept their deaths if they show up in poor shape. There are other alternatives.

  2. It’s important to start out slowly at the beginning of the season, and get your crew acclimated to the working conditions and environment. Place emphasis on your primary task; engine crews hike hills with hosepacks, handcrews hike and cut line, etc. Throw in some runs, calisthenics, and weight lifting to effectively cross train. Most importantly, take care of your people and allow for adequate rest and nutrition. Don’t run your crew into the ground before the season starts, but make sure they’re ready to face the physical demands of the job.

    1. Great suggestions. Supervisors can pull aside the people who are lagging and work with them; they should be able to release them if they don’t meet standards within a reasonable time.

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