Tag: heat related illness

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.

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…