Prevention of heat related injuries among wildland firefighters

When we were writing the July 13 article about Frank Anaya, the latest California inmate firefighter that died on a fire, we discovered details about a previous inmate fatality that were shocking. It involved the death of Jimmy Randolph in August of 2012 whose passing was associated with heat stroke. The shocking part was that Mr. Randolph was found unresponsive one morning in the sleeping area on a fire and died in a hospital seven hours later. He had complained of a headache the previous evening and was checked out by the medical unit, but apparently no one was aware of the seriousness of his condition.

Here is an excerpt from a summary of the fatality from wlfalswaysremember.org:

Firefighter Jimmy Randolph was assigned to the Buck Fire as a part of a strike team. At approximately 1800 hours on August 18, 2012, Firefighter Randolph advised a correctional officer that he had a headache. He was escorted to a medical team, evaluated, and given a three-day no-work note. At approximately 0530 hours the next morning, Fire fighter Randolph could not be awakened. He was treated and transported to the Desert Regional Hospital in Palm Springs. With his family by his side., he was pronounced dead at 1230 hours on August 19, 2012. The cause of death was listed as anoxic encephalopathy combined with complications of heat stroke.

Anoxic encephalopathy is a condition where brain tissue is deprived of oxygen and there is global loss of brain function. The longer brain cells lack oxygen, the more damage occurs.

I checked the weather for August 18, 2012 for San Jacinto, California which is in the general vicinity of the Buck Fire, and the high temperature that day was 92 degrees — a temperature commonly found on a large wildfire in the summer.

Today the National Multi-Agency Coordination Group: issued a memo titled, “Wildland Firefighter Heat Related Injury Prevention, Awareness, and Rhabdomyolysis”.

Here’s how it begins:

The wildland firefighter community has experienced an alarming increase in heat related and other physiological injuries in the last few days. Heat related injuries and Rhabdomyolysis are not the same, but can occur at the same time. Extreme weather conditions are predicted to continue across western states for the next week. The National Weather Service is issuing Heat Warnings for the SWCC, GBCC, RMCC, OSCC, and ONCC.

It is a very well-written document about how to prevent, mitigate, and recognize heat related injuries.

Read it, dammit.

You don’t want to wake up dead.

Full Stop.

Safely training the tactical athlete

Above: Firefighters on the Apple Fire, March 28, 2012. Photo by Bill Gabbert.

Today we are reprising a second article from our archives about heat related injuries and extreme physical exertion among wildland firefighters.

As we reported in the first Throwback Thursday article, Dr. Brent Ruby, who has studied firefighters as they worked on fires, said regarding the 2011 hyperthermia fatality on the CR 337 fire in Texas:

The lessons learned from this research clearly indicate that the best protection against a heat injury is reducing work rate.

Aggressive hydration strategies are over-preached and may provide a false sense of protection. It should be emphasized that the autopsy report as described in the fatality report indicated no signs of dehydration or electrolyte imbalance.

With that in mind, below is the article we wrote in 2016 after reports were released on two very serious injuries that occurred during the first two days of training for new firefighters.

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Safely training the tactical athlete

EMTAfter reading the Facilitated Learning Analysis (FLA) about the Rhabdomyolysis (Rhabdo) injury that occurred May 2, 2016 in South Dakota on the first day of the fire season after running for more than nine miles before doing uphill sprints, I started thinking about, not so much WHAT happened, but how to prevent similar serious injuries.

A couple of weeks before the Rhabdo case, on April 19 a wildland firefighter in the Northwest suffered a heat stroke while running on day 2 of their season. The employee was unconscious for several hours and spent four days in the hospital.

Both of these exercise-induced conditions can be life-threatening; 33 percent percent of patients diagnosed with Rhabdo develop a quick onset of kidney failure, and 8% of all cases are fatal.

Heat stroke can also kill, according to Medscape:

When therapy is delayed, the mortality rate may be as high as 80%; however, with early diagnosis and immediate cooling, the mortality rate can be reduced to 10%.

These two very serious incidents in a two week period that occurred at the beginning of the fire season should be a wakeup call for agencies employing wildland firefighters.

I am not a medical or exercise specialist, but neither were any of the four members of the South Dakota Rhabdo FLA team. It was comprised of a District Fire Management Officer, a Natural Resources Specialist, an Assistant Superintendent on a Hotshot crew, and an Assistant Fire Engine Operator.

A person might expect that for an exercise-induced injury that is fatal in eight percent of the cases, a medical expert and an exercise physiologist would be members of the team. The FLA concentrated on recognizing symptoms of Rhabdo, which is good. Firefighters need to be be informed, again, about what to look for. But the necessity of treating the symptoms could be avoided if the condition was prevented in the first place.

Prevention was not addressed in the document, except to mention availability of water. Dehydration isn’t the leading cause of Rhabdo, which is caused by exertion, but it can be a contributing factor.

With two life-threatening medical conditions on firefighting crews in a two-week period that occurred during mandatory exercise on day one and two of training, medical and exercise professionals perhaps could have evaluated what caused the injuries, and suggested how to design and implement a physical fitness program that would lessen the chances of killing firefighters on their first or second day on the job. But the LEARNING opportunity of the FLA was squandered.

The wildland fire agencies are not alone in hiring people off the streets and throwing them into a very physically demanding job. The military does this every day, as do high school athletic programs. There is probably a large body of research that has determined how to turn a person into an athlete without putting their lives in danger.

While the three firefighters and the natural resources specialist I’m sure meant well and did the best they could to write the FLA within the limits of their training and experience, the firefighting agencies need to get serious about a professional level exercise training program. After all, they are employing TACTICAL ATHLETES.

This issue is serious enough that the NWCG (since there is no National Wildland Firefighting Agency) should hire an exercise physiologist who can design, implement, and monitor a program for turning people off the street into tactical firefighting athletes.

The myth of drinking water

“Aggressive hydration strategies are over-preached and may provide a false sense of protection”, Dr. Brent Ruby said.

Above: Firefighter on the Shep Canyon fire in South Dakota, September 6, 2011. Photo: Bill Gabbert/Wildfire Today.

As we officially enter Summer this week in the northern hemisphere, it’s a good time to revisit an article we wrote in 2011 about heat-related injuries.

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After reading our excerpt and later the full document from the the Serious Accident Investigation Factual Report  for the hyperthermia fatality of Caleb Hamm on the CR 337 fire in Texas, we heard from Dr. Brent Ruby, who has completed studies on this exact issue, even having studied wildland firefighters while they were working on fires. In one of his studies he was monitoring a wildland firefighter outfitted with a core temperature monitor, an ambient temperature sensor, and a special Camelback hydration system that monitored his water intake. This firefighter experienced a heat-related illness, heat exhaustion, and had to be evacuated off the fireline by a helicopter. That was a terrible thing to happen to a firefighter, and I’m sure the researchers thought the same thing, but it was probably a once in a lifetime cornucopia of incredibly useful data. Dr. Ruby sent us this message, reprinted here with his permission:

I was bothered by the findings of the CR337 fatality report from the investigation team. There are issues within this case that are very similar to a published heat exhaustion case study we published recently (Wilderness and Environmental Medicine 22, 122-125, 2011, http://www.ncbi.nlm.nih.gov/pubmed/21664560). In this report, we document drinking behavior, activity patterns, skin and core temperatures in a subject that suffered heat exhaustion and required evacuation. The lessons learned from this research clearly indicate that the best protection against a heat injury is reducing work rate. [*the abstract from the study is below]

Aggressive hydration strategies are over-preached and may provide a false sense of protection. It should be emphasized that the autopsy report as described in the fatality report indicated no signs of dehydration or electrolyte imbalance. I have tried to push these concepts to crews and safety officers when I get a chance to speak to them at meetings. I was bothered by this fatality knowing that it is seemingly directly linked to some of our research findings. I have tried to emphasize this to anyone that will listen in the world of wildfire.

You can certainly review our website to gain a better understanding of the publications we have done from research with the WLFF http://www.umt.edu/wpem. We have a great deal of physiological data, hydration, energy demands of the job, importance of supplemental feedings, etc. from all our work over the years. This peer reviewed research provides objective, scientific evidence that can be used to to change or influence policy to enhance safety on the line.

Let me know if you have any questions.

Regards, Brent Ruby

Brent C. Ruby, Ph.D., FACSM

Director, Montana Center for Work Physiology and Exercise Metabolism, The University of Montana

* Here is the abstract from the study:

Wilderness Environ Med. 2011 Jun;22(2):122-5.

High work output combined with high ambient temperatures caused heat exhaustion in a wildland firefighter despite high fluid intake.

Cuddy JS, Ruby BC.

Montana Center for Work Physiology and Exercise Metabolism, The University of Montana, Missoula, MT 59812-1825, USA.

The purpose of this case study is to examine the physiological/behavioral factors leading up to heat exhaustion in a male wildland firefighter during wildland fire suppression. The participant (24 years old, 173 cm, 70 kg, and 3 years firefighting experience) experienced heat exhaustion following 7 hours of high ambient temperatures and arduous work on the fire line during the month of August. At the time of the heat-related incident (HRI), core temperature was 40.1 °C (104.2 °F) and skin temperature was 34.4 °C (93.9 °F). His work output averaged 1067 counts·min(-1) (arbitrary units for measuring activity) for the 7 hours prior to the HRI, a very high rate of work over an extended time period during wildfire suppression.

In the 2.5 hours leading up to the heat incident, he was exposed to a mean ambient temperature of 44.6 °C (112.3 °F), with a maximum temperature of 59.7 °C (139.5 °F). He consumed an average of 840 mL·h(-1) in the 7 hours leading up to the incident and took an average of 24 ± 11 drinks·h(-1) (total of 170 drinks). The combined effects of a high work rate and high ambient temperatures resulted in an elevated core temperature and a higher volume and frequency of drinking than typically seen in this population, ultimately ending in heat exhaustion and removal from the fire line.

The data demonstrate that heat-related incidents can occur even with aggressive fluid intake during wildland fire suppression.

Unfortunately, even though Dr. Ruby’s research is funded by taxpayers through the National Institutes of Health, the National Science Foundation, and the Department of Defense, taxpayers are blocked from seeing the full results unless they pay a fee to the privately owned company that published the paper. We have written before about the results of taxpayer-funded wildfire-related research being held hostage by private companies. Dr. Ruby told Wildfire Today that he will send a copy of his paper to individuals that write to him at brent dot ruby at mso dot umt dot edu

The combined information about the fatality of Caleb Hamm on the CR 337 fire and Dr. Ruby’s study on wildland firefighters, is shocking. From the abstract, again:

The data demonstrate that heat-related incidents can occur even with aggressive fluid intake during wildland fire suppression.

Working on a wildfire on a hot day can lead to heat exhaustion and hyperthermia, and can be fatal EVEN IF a person drinks plenty of water and is not dehydrated.

Symptoms and prevention

We asked Dr. Ruby for more information:

Exertional hyperthermia occurs when the metabolic heat production from hard work overwhelms the bodies ability to off load it to the environment. This unloading can be blocked by clothing and/or slowed due to high radiant heat from the sun or an adjacent fire.

The basic symptoms of heat exhaustion are commonplace and can include profuse sweating, weakness, nausea, sometimes vomiting, lightheadedness, headache and sometimes mild muscle cramps.

The best approach [to prevent heat exhaustion and hyperthermia] is to know thyself and thy physical limits. Establishing a pace schedule that allows temperature to come back down in between periods of work that result in a rise in temperature. The factors of importance are pace, fitness level for the task at hand, hydration behaviors and simultaneously electrolyte concentrations in the blood.

It is important for wildland firefighters to drink plenty of water, but this will not, by itself, totally eliminate all chances of heat-related illness.

Be careful out there.

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UPDATE  October 27, 2011:

Dr. Ruby sent us the following list of other publications on similar topics that are in peer reviewed journals. I assume that most of them are not available to the public (don’t get me started on that again!) unless you pay the ransom fees at the private companies, or send a message to Dr. Ruby:  brent dot ruby at mso dot umt dot edu

Dr Ruby articles

====================

UPDATE October 28, 2011:

The U.S. National Library of Medicine has an excellent article about heatstroke, which can follow heat cramps and heat exhaustion and is life-threatening. The article includes causes, symptoms, first aid, what not to do, when to call 911, and prevention (including “avoid exercise or strenuous physical activity outside during hot or humid weather”. Good luck with that one, firefighters.)

Safely training the tactical athlete

EMTAfter reading the Facilitated Learning Analysis (FLA) about the Rhabdomyolysis (Rhabdo) injury that occurred May 2 in South Dakota on the first day of the fire season after running for more than nine miles before doing uphill sprints, I started thinking about, not so much WHAT happened, but how to prevent similar serious injuries.

A couple of weeks before the Rhabdo case, on April 19 a wildland firefighter in the Northwest suffered a heat stroke while running on day 2 of their season. The employee was unconscious for several hours and spent four days in the hospital.

Both of these exercise-induced conditions can be life-threatening; 33 percent percent of patients diagnosed with Rhabdo develop a quick onset of kidney failure, and 8% of all cases are fatal.

Heat stroke can also kill, according to Medscape:

When therapy is delayed, the mortality rate may be as high as 80%; however, with early diagnosis and immediate cooling, the mortality rate can be reduced to 10%.

These two very serious incidents in a two week period that occurred at the beginning of the fire season should be a wakeup call for agencies employing wildland firefighters.

I am not a medical or exercise specialist, but neither were any of the four members of the South Dakota Rhabdo FLA team. It was comprised of a District Fire Management Officer, a Natural Resources Specialist, an Assistant Superintendent on a Hotshot crew, and an Assistant Fire Engine Operator.

A person might expect that for an exercise-induced injury that is fatal in eight percent of the cases, a medical expert and an exercise physiologist would be members of the team. The FLA concentrated on recognizing symptoms of Rhabdo, which is good. Firefighters need to be be informed, again, about what to look for. But the necessity of treating the symptoms could be avoided if the condition was prevented in the first place.

Prevention was not addressed in the document, except to mention availability of water. Dehydration isn’t the leading cause of Rhabdo, which is caused by exertion, but it can be a contributing factor.

With two life-threatening medical conditions on firefighting crews in a two-week period that occurred during mandatory exercise on day one and two of training, medical and exercise professionals perhaps could have evaluated what caused the injuries, and suggested how to design and implement a physical fitness program that would lessen the chances of killing firefighters on their first or second day on the job. But the LEARNING opportunity of the FLA was squandered.

The wildland fire agencies are not alone in hiring people off the streets and throwing them into a very physically demanding job. The military does this every day, as do high school athletic programs. There is probably a large body of research that has determined how to turn a person into an athlete without putting their lives in danger.

While the three firefighters and the natural resources specialist I’m sure meant well and did the best they could to write the FLA within the limits of their training and experience, the firefighting agencies need to get serious about a professional level exercise training program. After all, they are employing TACTICAL ATHLETES.

This issue is serious enough that the NWCG (since there is no National Wildland Firefighting Agency) should hire an exercise physiologist who can design, implement, and monitor a program for turning people off the street into tactical firefighting athletes.

Lesson learned: heat-related illness

Lesson learned, heat related illness

A crewperson on an Angeles National Forest hotshot crew had a close call in June with a heat-related illness. While engaged in strenuous physical activity, the firefighter developed severe cramps and had a temperature two degrees lower than normal. During a five-hour period he or she drank all the water from their 100-ounce Camelback once, and again later after refilling it, plus two Gatorades.

The EMTs on the crew who recognized the serious potential of the person’s condition arranged for transportation to a hospital. It turned out to be a mild case of rhabdomyolysis which, if not caught in time and treated can be fatal. The EMT that accompanied the firefighter to the hospital insisted that tests for rhabdo be done, even though the staff at the hospital had not planned on doing the tests.

The hotshot also had hyponatremia, which is a severe imbalance of water to salt. Drinking large quantities of water without enough fluids with electrolytes can cause hyponatremia.

Congratulations to the hotshot crew and the EMTs for making good decisions during this serious incident.

You can read the entire report here, but below are the Lessons Learned:

  • Know yourself and know each other. Each person must monitor their water and sports drink intake. Supervisors must ensure all crewmembers are getting adequate electrolyte replacement.
  • Recognize fatigue and take action early, before it can lead to a heat-­related illness. This may require taking breaks due to environmental conditions.
  • Do not count on observing classic heat-­‐illness symptoms; patient may not present the symptoms you have been trained to look for.
  • The patient is not the one who decides if he or she goes to the hospital. It is the decision of the first responder, EMT, or higher-­‐ranking individual, due to the nature and/or severity of the injury/illness and/or agency protocol.
  • If employees are treated for heat-­‐related illness, the treating facility should be asked to check for rhabdomyolysis. The patient’s representative must insist that CPK, potassium phosphate, and myoglobin tests are done initially and on the follow up appointment.

In 2007 a California radio station held a contest to see who could win a Wii game console by drinking the most water without going to the bathroom. Jennifer Strange, a 28-year-old mother of three, died of hyponatremia after drinking about two gallons of water. A jury found the radio station liable, and awarded her husband $16.5 million.

We have written previously about the “Myth of drinking water”. Some may assume that drinking lots of liquids will prevent heat related illnesses, but that is not always the case. In the article, we quoted Dr. Brent Ruby, who has conducted research in this area. In the quote below he was referring to the 2011 Caleb Hamm fatality on the CR337 Fire in Texas. Mr. Hamm was a member of the Bureau of Land Management’s Bonneville Interagency Hotshot crew.

Dr. Ruby:

I was bothered by the findings of the CR337 fatality report from the investigation team. There are issues within this case that are very similar to a published heat exhaustion case study we published recently (Wilderness and Environmental Medicine 22, 122-125, 2011, http://www.ncbi.nlm.nih.gov/pubmed/21664560). In this report, we document drinking behavior, activity patterns, skin and core temperatures in a subject that suffered heat exhaustion and required evacuation. The lessons learned from this research clearly indicate that the best protection against a heat injury is reducing work rate…

Inmate firefighter dies after falling ill on California fire

The 2,681-acre Buck Fire south of Hemet, California, was fully contained on Friday morning, and the North County Times reported that an inmate firefighter died yesterday after he became ill on the fire.

The California Department of Corrections and Rehabilitation (CDCR) and Cal Fire are investigating the illness and subsequent death of 44-year-old Jimmy Randolph, who died at a hospital in Palm Springs with his family at his bedside. The cause of death will be announced after an autopsy is completed.

(UPDATED July 13, 2017. Mr. Randolf died in a hospital August 19, 2012 seven hours after he was found unresponsive where he was sleeping at the fire. The cause of death was listed as anoxic encephalopathy combined with complications of heat stroke.)

Buck Fire location

Fenner Canyon Conservation Camp on the Angeles National Forest houses minimum-security inmates and is operated jointly by CDCR and Cal Fire.

The Buck Fire also had a microburst rip through the ICP early Thursday, with hard rain and hail and 60 mph gusts that sent tents and much of the camp skittering across the ground. The fire, ignited by lightning last Tuesday, was also plagued with injuries; according to the Desert Sun, one firefighter was taken to a hospital for minor injuries. Three other firefighters incurred minor injuries, along with two civilians, one of whom suffered severe third-degree burns to his legs.

Riverside County Sheriff’s deputies are investigating a marijuana patch discovered in the area. According to the L.A. Times, firefighters encountered two men trying to protect the small grove of plants.

This fire had more than its share of weirdness. The Desert Sun also reported that a 59-year-old local man was charged with driving over a fire captain’s foot on Tuesday afternoon. Gregory Lance Good is being held in lieu of $30,000 bail on charges of assault with a deadly weapon and interfering with a firefighter in the line of duty. He was arraigned in Riverside County Superior Court and entered a “not guilty” plea.