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.


Another serious injury during PT at beginning of fire season

The firefighter spent four days in the hospital after suffering heat stroke.

Another firefighter has sustained a very serious injury during physical training at the beginning of their fire season. The first one that we are aware of this year occurred on May 2 in South Dakota when on the first day of training the firefighter was diagnosed with Rhabdomyolysis.

The Wildland Fire Lessons Learned Center just released a “72 hour report” from the Pacific Northwest Region about an April 19 heat stroke victim that happened on the second day.

firefighter heat stroke

Both of these conditions are extremely serious and in the worst case, can lead to death.

It must be very difficult to develop a perfect exercise regimen for all 20 people on a hand crew. Especially at the beginning of the season when some of the experienced firefighters may have had an ongoing physical fitness program during the off season, and others are brand new, never having held a shovel, and may have spent the winter on a couch.

Firefighter diagnosed with Rhabdo hours after PT on first day of training

A firefighter on the Tatanka Hotshots in South Dakota was admitted to a hospital hours after completing a long run on the crew’s first day of the 2016 fire season. The run began at 10 a.m. on May 2 and later in the day he complained of severe cramping. The diagnosis was Rhabdomyolysis, sometimes shortened to Rhabdo, and he remains hospitalized as of May 6 according to the “72-hour notification”. A Facilitated Learning Analysis (FLA) team will in-brief on May 9.

Employee's left leg after 5 surgeries
Complications from Rhabdo. Another firefighter’s left leg after 5 surgeries in 2011. Photo from the FLA.

Rhabdo is the breakdown of muscle fibers resulting in the release of muscle contents (myoglobin) into the bloodstream which are harmful to the kidneys and may lead to kidney failure.

Left untreated, or if not treated early enough, rhabdo can lead to irreversible muscle damage, permanent disability, kidney failure possibly requiring lifelong dialysis, and even death. Up to 8% of cases of rhabdomyolysis are fatal according to a NIOSH report. And all of this can be the result of exercising hard or engaging in a strenuous fire assignment if other risk factors are also present.

Articles on Wildfire Today tagged rhabdomyolysis.

The Missoula Technology Development Center recently released this publication about Rhabdo, and the NWCG issued this poster.

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…

Lessons Learned Review: Rhabdomyolysis leading to heat stroke

PT run trail
Trail on which the PT run was conducted. NPS photo.

A Lessons Learned Review (LLR) for an unusual but severe injury has been released. A firefighter working for the National Park Service at Sequoia and Kings Canyon National Parks in California developed rhabdomyolysis (rhabdo) during his first week of work this season, probably after his first day which included very strenuous physical training. Then four days later, on June 27, 2013, he suffered from heat stroke during a training run. Recent research indicates that muscle damaging exercises can increase heat strain during subsequent exercise.

The firefighter was treated by NPS medics at the scene and then transported by a California Highway Patrol helicopter with a paramedic on board. He arrived at a Level I trauma center within one hour and thirty three minutes of his collapse while running. The doctor at the hospital told his parents that he was “…a profoundly sick young man, who may not make it.” He was hospitalized for two weeks and underwent kidney dialysis three times a week for seven weeks; reduced to once a week at the time the report was written, and was projected to make a full recovery. He hopes to return to light duty work, but cannot do so until he is finished with kidney dialysis treatments.

An excerpt from the report:

The LLR Team would like to commend the EMS responders, both from the NPS and the CHP, for their quick- thinking and actions. The LLR Team is certain that if these employees had not done so, [the firefighter’s] injury would have proved fatal.

The report, written by a four-person team that included an Exercise Physiologist with a PH.D., is very well written. It includes numerous recommendations for sustaining good practices as well as suggestions for improving the handling of rhambdo and other serious injuries, both locally and nationally.

All firefighters should read this Lessons Learned Review.

Heat stroke and rhabdoMore information and heat illness and its prevention.

Other articles at Wildfire Today about rhabdomyolysis.


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.