Rhabdomyolysis Lessons Learned Review – Sequoia and Kings Canyon National Parks 1

Rhabdomyolysis Lessons Learned Review

Sequoia and Kings Canyon National Parks

June 28-30, 2016

Bob is not exactly your typical wildland firefighter. He is 40 years old. He doesn’t drink alcoholic

beverages. He refrains from energy drinks, drinks only one cup of coffee per day, and adheres to

a balanced, healthy diet with ample servings of fruit and vegetables.

Therefore, it was puzzling to him when one afternoon he noticed his urine was the color of light

tea. The color “struck me as curious” says Bob, considering that his engine crew had only played

volleyball that day for PT.

The System is Working “In this case, education may have prevented an acute medical emergency.”

Park FMO

Rhabdomyolysis Lessons Learned Review – Sequoia and Kings Canyon National Parks 2

Contents

A. Review Objectives……………………………………………………………………………………………. 2

B. Narrative………………………………………………………………………………………………..………… 2

Patient Background……………………………………………………………………..………………… 2

Timeline of Events……………………………………………………………………………………..….. 3

C. Observations from the Park Fire Staff and Lessons Learned Review Team………… 7

Sequoia and Kings Canyon National Parks Background……………….…………..…….. 7

Observations from the Park Fire Staff…………………………………………………………….. 8

Observations from the Lessons Learned Review Team……………………….………….. 8

D. Lessons Learned and Recommendations from the Park Fire Staff…………..………… 9

E. The Specific Role of Rhabdomyolysis Education……………………………………………….. 10

F. Final Thoughts from the Lessons Learned Review Team: The System is Working 11

G. The Lessons Learned Review Team………………………………………………………….………. 13

A. Review Objectives

On June 28, 2016, a National Park Service firefighter noticed that he had symptoms relating to a potential exertion illness. Two days later he was admitted to the hospital and subsequently diagnosed with Rhabdomyolysis. A Lessons Learned Review Team was given a delegation of authority on July 12 to focus on three specific issues for Organizational Learning:

1. Upstream factors that contributed to the Rhabdomyolysis event.

2. The post incident response.

3. Recommendations for the Park staff and others to reduce the probability of such an event occurring in the future.

B. Narrative

Patient Background Bob has worked as the permanent subject-to-furlough Engineer on a Type 3 Engine at Sequoia and Kings Canyon National Parks (SEKI) since July, 2014. Prior to coming to SEKI, he worked on a wildland engine for the U.S. Fish and Wildlife Service at a refuge in south Florida for seven years. He has a total of 13 years of experience as a wildland firefighter.

Bob’s fire station is located in the Sierra Nevada foothills at an elevation of around 1,200 feet (see photos on next page). Summers are characterized by long months of hot weather with temperatures frequently over 100 degrees. Bob found the drier heat relatively more tolerable compared to Florida and considers himself acclimated. He is also physically fit and is described as one of the better hikers on his crew.

Rhabdomyolysis Lessons Learned Review – Sequoia and Kings Canyon National Parks 3

On April 25, 2016, Bob had surgery on his right knee to repair a torn meniscus. He was on light duty and doing rehab until getting cleared by the doctor on June 9. On June 11, SEKI began a large prescribed burn. After consulting with his supervisor and the District FMO, it was decided that Bob would sit the burn out and help with fire information. Bob would be given time to do PT during the burn and would ease back in rather than plunge right back into arduous duty.

On June 18, Bob took the arduous Pack Test and rejoined his crew full time with no limitations.

“Nothing too crazy, nothing too soft, just a happy medium.”

Assistant Fire Engine Operator, Referring to their PT program

Timeline of Events The engine crew’s PT program generally consists of alternating run days with gym days. Runs are typically self-paced and gym workouts are done with a large degree of independence. The philosophy is that individuals know what they need to work on and how much they should push themselves.

The Engine Captain describes their PT as being “pretty easy relative to the other [Park fire] modules.” The week prior to the incident was described as “normal PT; normal work”. The crew did daily PT, three to four hours weed-eating one day for project work, station maintenance, training, etc.

In the days prior to Bob’s medical incident, the crew’s PT consisted of:

June 25 Self-paced 1.5 mile run. Because he shuttled vehicles, Bob estimated that he ran for only 10-15 minutes.

June 26 “Deck of Cards” day which consists of going through a deck of cards and using each card’s numeric value to do sit-ups, pull-ups, push-ups, squats, lunges, bar dips, etc. Lots of push-ups were done on this day. Bob was said to be “struggling with push-ups, but that was normal.” (Bob generally focuses his personal PT on his lower body which he feels is more important to his engine crew position than arm strength.)

Bob’s Sequoia and Kings Canyon National Parks fire station is located in the Sierra Nevada foothills at an elevation of around 1,200 feet.

Rhabdomyolysis Lessons Learned Review – Sequoia and Kings Canyon National Parks 4

June 27 Four-mile roundtrip self-paced run, mostly uphill on a moderate grade one way and downhill coming back (see photos above). Everyone was said to be a little sore from the previous day.

June 25-27 These were station days where the crew worked on tools, hose, and station projects. This work was not arduous.

June 28 This day started out with the crew playing volleyball for PT. Afterwards, the crew participated in an FLA review and discussion of the Rhabdomyolysis incident on the Nez Perce National Forest (see this FLA’s cover on right).

At 1300, Bob noticed for the first time that his urine was light tea colored. His urine cleared up around 1700, but went back to being tea colored around 2100 that evening.

“If you have colored urine, let me know.”

Bob addressing his crew while reviewing the Nez Perce NF Rhabdo FLA

(The morning before his own symptoms showed up.) June 29

This would normally have been a day off for the crew. However, Bob and another firefighter, Luis, were brought on to patrol the recently completed Goliath Prescribed Burn. Prior to going to work, Bob noticed that his urine was still tea colored. After his usual routine of taking his dogs on a one-mile neighborhood walk, having one cup of coffee, one large glass of water, and eating a bagel with cream cheese, Bob reported to work at 0915.

The route of the engine crew’s four-mile, self-paced run.

On June 28, Bob’s engine crew reviewed and discussed this FLA

Rhabdomyolysis incident on the Nez Perce National Forest .

Rhabdomyolysis Lessons Learned Review – Sequoia and Kings Canyon National Parks 5

The Goliath Burn is located in mixed conifer forest and ranges from 5,500 to 6,420 feet in elevation (see map on right). It’s a short hike in and surrounded by 7.3 miles of gentle to moderately graded trail. There are a few short, but steep pitches where the perimeter cuts off trail switchbacks.

The Park was in the midst of a heat wave, which is normal for the time of year. Weather readings at the nearest RAWS at 7,540 feet showed a maximum temperature of 80 degrees and relative humidity hovering between 30-42 percent during most of the day.

Being significantly lower and located in a broad canyon bottom, maximum temperatures on the burn unit are estimated to have been in the mid-80s, with humidity hovering around 35-45 percent. Luis remembered it “feeling hot but the humidity wasn’t that bad.”

Arrive at Burn Unit Bob and Luis arrived at the burn unit parking area around 1130. Bob remembers drinking about 20 ounces of water on the drive up and noticed that his urine was still tea colored upon arrival. He also noticed tenderness/soreness in his upper abdomen and lower pecs, possibly due to the push-ups from two days ago. As is normal, Bob was consciously hydrating.

“It seemed out of place and rare for me to feel soreness.”

Bob referring to his upper body pain

“It [the hiking] caught my attention because my normal stamina wasn’t there.”

Bob

Bob Becomes Troubled By His Fatigue The pair did a patrol lap around the burn, stopping for lunch around 1300. Bob estimated that he drank at least a gallon of water during the patrol. Around 1500, Bob noted that his urine color had slightly darkened. Sometime around 1530, his hiking slowed.

Bob had to stop a couple times on hills to catch his breath as he was getting winded. Being stationed around 5,000 feet below the burn, it’s not unusual for the crew to feel winded at this elevation. However, Bob was troubled by his fatigue.

Tea colored urine was observed again at 1610 and at 1719 when they completed the patrol. At this point, Bob began documenting the exact times of his condition.

Rhabdomyolysis Lessons Learned Review – Sequoia and Kings Canyon National Parks 6

“I kind of knew the night before. I was fairly certain it was Rhabdo.”

Bob That Night Bob Calls His Supervisor Other than discolored urine and a little soreness, Bob felt essentially normal. After he returned home that evening, he walked his dogs as usual and had dinner. Even so, Bob was concerned about his symptoms and contacted his supervisor at 2020.

They determined that if his urine was still discolored in the morning, they would meet at the fire station at 0930, fill out the paperwork, and go to the hospital. Prior to going to bed, there was no change in Bob’s urine color.

“I know my body well enough to know that I was going to be gone for a couple days.”

Bob Bob Goes to the Hospital That next morning, on June 30, Bob’s urine is still discolored and there is tenderness/soreness on the front side of both of his armpits.

He walks his dogs, has his standard cup of coffee, plenty of water, and breakfast. But today, before leaving, he does some light household chores and packs an overnight bag for the hospital. He knows by this time that he’s going to the Emergency Room.

Bob and his supervisor arrive at Kaweah-Delta Hospital in Visalia around 1030. They tell the check-in nurse of possible Rhabdo and give her the one-page “Rhabdo Handout for Medical Providers.”

Acute Rhabdomyolysis is Confirmed The doctor who sees Bob was familiar with Rhabdo from recent local cases and agrees it’s a possibility. Bob has blood drawn and is given an IV.

Around two hours later, the doctor brings back Bob’s blood results. They confirm the diagnosis as acute Rhabdomyolysis with slight dehydration. Bob’s CPK (serum creatine phosphokinase) levels are elevated to 99,000 units per liter (U/L). Normal levels range from 45-260 U/L (according to: Efstratiadis, G. et al. “Rhabdomyolysis Updated.” Hippokratia 11.3 (2007): p. 129-137).

The doctor expresses surprise that Bob is not showing more severe symptoms and that he actually has the ability to be walking around.

Bob is officially admitted to the hospital and remembers having at least five IV bags that day. His blood is drawn every 12 hours.

The one-page Rhabdo handout for medical providers that all crew leaders should have to present when they take firefighters exhibiting possible Rhabdo

symptoms to the hospital.

The doctor expresses surprise that Bob is

not showing more severe symptoms and

that he actually has the ability to be

walking around.

Rhabdomyolysis Lessons Learned Review – Sequoia and Kings Canyon National Parks 7

Bob’s subsequent CPK levels (normal levels range from 45-260 U/L):

June 30 at 1800: 62,000

June 30 at midnight: 69,000

July 1: 64,000; an ultrasound reveals no liver or kidney abnormalities

July 2: 29,000

July 3: 14,000

Bob is released from the hospital at 1200 on the July 3. His discharge instructions are to:

Eat his regular diet as can be tolerated.

Increase fluid intake with Gatorade and water.

Limit activity to remaining in the house and taking it easy for one week.

Check in with his regular doctor within the next week.

Return to light duty on July 11 with limited physical activity and sun exposure until August 11.

On July 14, Bob’s CPK levels had dropped to 1,100 and the doctor felt that no more blood tests were necessary. He had his final check-up on August 10. He was cleared to resume regular duties on August 11.

C. Observations from the Park Fire Staff and Lessons Learned Review Team

Background Awareness of Rhabdomyolysis at Sequoia and Kings Canyon National Parks (SEKI) is already very high.

In 2013, a fuels crew member on the Park nearly died from heat stroke/Rhabdomyolysis following a PT run. After a Life Flight, this individual was in critical condition for six days, hospitalized for two weeks, and was on kidney dialysis for seven weeks.

Lessons from this 2013 incident were documented in the subsequent “Physical Training Run Incident – Rhabdomyolysis Leading to Heat Stroke Lessons Learned Review”. All SEKI fire modules are now required to review this document prior to going available for the fire season.

Also, after this incident, a programmatic change was made: No additional PT would be allowed the same day as the Pack Test.

Park FMO Sends Out Rhabdo Message On June 28, the same day Bob began experiencing his first symptoms, the Park FMO sent the following email message to all SEKI fire module supervisors. (The FLA referred to in the email was the Nez Perce National Forest’s Rhabdomyolysis incident.) After receiving the email, Bob’s engine crew reviewed this FLA after PT.

“Please read the attached FLA regarding Rhabdo. With the record heat we'll be experiencing over the next week, we have the potential for heat illness. Rhabdo often is coupled with heat illness. A clear message from the FLA is dark urine (cola colored) may not be dehydration, but instead Rhabdo.

All SEKI fire modules are required to review this 2013 Lessons Learned

Review prior to going available for the fire season.

Rhabdomyolysis Lessons Learned Review – Sequoia and Kings Canyon National Parks 8

The FLA has an accompanying Rhabdo fact sheet for medical staff. They suggest printing out the flyer and keep it in your Crew Boss kit—a good idea. I found the FLA clear and to the point. Well written.”

“It came out of left field.”

Engine Captain, on Bob’s Rhabdomyolysis

“We stay hydrated, especially Bob with the ice machine.”

Engine AFEO

Observations from the Park Fire Staff Members of Bob’s engine crew and SEKI fire managers were unanimous in their surprise that Bob was a victim of Rhabdomyolysis. He is physically fit, familiar with working in the heat, and is seen throughout each day making a conscious effort to drink water and stay hydrated.

Bob had no prior incidences of dehydration, heat stroke, or Rhabdo. After passing the Pack Test on June 18, in the week prior to the Rhabdo incident he was observed to be “getting stronger and stronger with his running.”

Equally important is that in the week prior to his Rhabdo incident, there were no identifiable alterations in Bob’s eating habits, PT, work schedule, or work tasks. Crewmembers consistently stated that the prior week was “normal,” both for PT and projects.

“It doesn’t appear necessary for there to be extreme physical exercise, the normal range of physical exertion of

firefighters is enough to cause Rhabdo.”

Park FMO

Observations from the Lessons Learned Review Team If there was any type of connection between Bob and Rhabdo, it’s that a member of Bob’s immediate family, as well as a member of his extended family, had been previously diagnosed with Rhabdo. Some studies have shown there could be genetic considerations that can predispose someone to Rhabdo. But in the absence of specific and substantial research, it remains unknown whether there is a hereditary link which made Bob more prone to Rhabdomyolysis.

Bob’s prior knee surgery on April 25 may have indirectly contributed to his onset of Rhabdo. During his post-surgery recovery period, Bob experienced decreased physical activity. Returning to PT, especially after rehabbing and recovering, can be rough on muscles and cause them to be easily overworked or shocked. Under this scenario, a rapid or sudden increase in physical activity is something muscles are not used to and, thus, can cause undue fatigue.

In addition, during his knee surgery recovery time, Bob had not been doing any upper body workouts, focusing instead on his lower body. Therefore, it’s possible that the most significant Rhabdo contributor may have been Bob’s return to PT after surgery and the calisthenics, including his engine crew’s “Deck of Cards” workout on June 26.

Rhabdomyolysis Lessons Learned Review – Sequoia and Kings Canyon National Parks 9

“There is nothing wrong with doing these workouts. They are recommended and are great callisthenic workouts which are good for

firefighters. However, when they are done after a long period of not engaging in these exercises and especially at high reps,

they can overload muscles too much.”

Molly West, Research Assistant U.S. Forest Service National Technology and Development Program,

referring to “Deck of Cards” type of physical workouts Contributing Rhabdo Factors Remain a Mystery It cannot be definitively determined whether Bob’s knee surgery contributed to the incident. After all, he was known to be physically fit and has worked the majority of his fire career in the hot and humid environment of south Florida. The lack of distinctive contributing factors remains a mystery to all those involved.

D. Lessons Learned and Recommendations from the Park Fire Staff

“It doesn’t seem like there is a singular cause.

It must have been a combination of factors as a whole contributing to my incident.

I encourage firefighters to be honest with themselves and their supervisor in reference to how their bodies

feel. Be brave enough to bring the situation to your supervisor.

Set pride and ego aside for the benefit of your health.”

Bob

Bob himself is the first to admit that he was surprised that he came down with Rhabdomyolysis. He doesn’t know for certain whether his knee injury was a factor. After his knee surgery, he was eased back into both PT and arduous work following his light duty.

By observing, documenting, and then notifying his supervisor about his potential Rhabdo symptoms, Bob feels he handled the situation methodically and well.

Other than continuing to maintain close body awareness, Bob does not plan to change his routine in the future. He is also fully aware that by paying attention to—rather than ignoring—his symptoms prevented a much more serious injury.

Specific Lessons from Bob, His Engine Crew, and Park Staff

Wildland firefighting is a young man’s game. It’s very different being 40 versus being in your early 20s. You have to be mentally aware and take every advantage you can to stay in shape.

Place more emphasis on looking at symptoms. Dig deeper into getting an explanation of what people are feeling.

Rhabdomyolysis Lessons Learned Review – Sequoia and Kings Canyon National Parks 10

Know the symptoms of Rhabdo, recognize them early, and act on it. If you feel signs coming on, then say something.

Send people to the doctor sooner than later if there’s a dark urine indicator or if Rhabdo is suspected. Don’t wait to see if the symptoms continue or progress to something more severe. Always err on the side of safety.

The Engine Captain informed: “We have another example of something [Bob’s Rhabdo case] that we now need to be talking about all the time.”

“I told them to get him to the hospital and we’ll sort out the paper work later. It would be good to clean

this up. Is it a CA-1 or CA-2?”

District FMO

Additionally, there was some administrative confusion over which forms were required immediately prior to taking Bob to the hospital. Fortunately, this did not result in a delay getting treatment.

SEKI has confirmed that for suspected cases of Rhabdomyolysis, the correct forms are the CA-1 and CA-16.

E. The Specific Role of Rhabdomyolysis Education

“It’s hard to make a change without being able

to pinpoint the cause.”

Engine Captain, on whether he’ll change the PT

or other aspects of their program

It gets trickier when supervisors and managers are asked what specific changes they will make in the future. With two Rhabdo cases in the past three years, SEKI fire managers can’t help but do some soul searching.

Bob’s particular case raises more questions than answers. Some questions Park fire managers are now considering:

Should firefighters be eased into PT at the start of each season?

Should there be a formal process for integrating seasonal employees into a PT program who report to work later than their module’s start date?

Should there be a similar process for individuals coming back to arduous duty after an injury?

What is the balance between a rigorous PT program and pushing people too far?

Should PT be limited during heat waves?

How do firefighters acclimatize to working in the heat without training in it?

Is there a happy medium? If so, what is it?

Rhabdomyolysis Lessons Learned Review – Sequoia and Kings Canyon National Parks 11

“Bob’s Rhabdo case is a success story by reacting to what’s been in the FLAs. If it [the Nez Perce National Forest Rhabdo

FLA] hadn’t been fresh in his mind, Bob’s symptoms might have been discounted.”

District FMO

“Education is important and may have in this case prevented an acute medical emergency.”

Park FMO Importance of Rhabdo Education In summary, there is one clear lesson arising from Bob’s case: the importance of Rhabdomyolysis education.

If Bob had not recognized through training—whether from that day or the previous year—that his symptoms signified the possibility of Rhabdomyolysis, his case could have been much more severe.

The 2013 SEKI Rhabdo incident ended the career of a fine young firefighter. Bob, fortunately, was not as unlucky.

SEKI fire managers can’t emphasize enough to all wildland fire units across the nation to:

EDUCATE AND TRAIN YOUR FIREFIGHTERS ABOUT THE SYMPTOMS AND DANGERS ASSOCIATED WITH RHABDOMYOLYSIS!

F. Final Observations from the Lessons Learned Review Team: The System is Working

Recommended Self-Documentation for Firefighters When a firefighter is diagnosed with Rhabdomyolysis, a big part of the mystery is reconstructing the events that led up to it. Key components include what an individual ate, drank, did for PT, and their work history in the 7-10 days prior to the Rhabdo onset. With that in mind, firefighters should consider the following:

Keep a daily log to accurately and thoroughly document PT. Generic entries such as “PT – Crew Run” should be elaborated into more detail (“Crew Run, 5 miles, 700’ elevation gain”).

Accurately and thoroughly document daily project work.

Document the weather daily, even when not on a fire assignment.

Track daily food and fluid intake to the best extent possible.

Note any unusual muscle soreness, change in fatigue levels, and other indicators of dehydration, heat illness, and/or Rhabdomyolysis.

Making this documentation part of a short, daily routine will go a long way toward identifying upstream factors leading to a particular event.

Rhabdomyolysis Lessons Learned Review – Sequoia and Kings Canyon National Parks 12

Final Thoughts – The System is Working as Designed It can be considered ironic that the day the Nez Perce National Forest Rhabdo FLA was made available, the SEKI Park FMO sent his email, the engine crew reviewed the FLA, and Bob’s Rhabdo symptoms appeared. However, beyond the onset of his symptoms, there is little else coincidental about this.

Reports of Rhabdomyolysis have been on the rise for the past five years. Most summer months do not pass without yet another heat related illness or Rhabdo FLA and their associated lessons becoming available.

The majority of the observations and lessons learned in this particular review are common ones. They have appeared in nearly every FLA or report concerning Rhabdomyolysis for the past few years. Until it actually happens to your unit, some people are even concerned about “potential Rhabdo fatigue.”

Nonetheless, Bob’s case classically proves that the system is working as designed.

Incidents are being reported and rolled up.

Reviews and FLAs are being completed.

These documents are being disseminated to the greater fire community.

Firefighters are reading these documents.

Firefighters are recognizing the Rhabdo and heat stress symptoms.

Firefighters are reacting and are changing their behavior.

Both Our Blessing and Our Curse Most wildland firefighters have probably “sucked it up” when feeling poor in the past. Recent heat stress and Rhabdomyolysis FLAs have indeed shown this tendency to occur during strenuous, early season PT. The nature of wildland firefighting attracts individuals of this nature. It is both our blessing and our curse.

Bob could have noticed the discoloration in his urine and elected to tough it out. If he had ignored his symptoms, there is a good chance he could have ended up in the hospital for a much longer stay and risked permanent damage to his kidneys or liver. But he didn’t. He did the right thing and he will now live on to fight fire another day.

For additional information, click on this link: Rhabdomyolysis Awareness and Education.

Rhabdomyolysis Lessons Learned Review – Sequoia and Kings Canyon National Parks 13

G. The Lessons Learned Review Team

Ben Jacobs, Lead Parks Fuels Management Specialist (Retired), Sequoia and Kings Canyon National Parks

Paul Keller

Technical Writer-Editor, Wildland Fire Lessons Learned Center

With special appreciation to the following people for their review and comments:

Members of the Sequoia and Kings Canyon Fire and Ranger Staff

Brit Rosso Director, Wildland Fire Lessons Learned Center

Alex Viktora

Field Operations Specialist, Wildland Fire Lessons Learned Center

Molly West Research Assistant, U.S. Forest Service National Technology and Development Program

Dr. Joe Domitrovich

Exercise Physiologist, U.S. Forest Service National Technology and Development Program