Pack Test Compartment Syndrome FLA - Wildland Fire Lessons ...

Work Capacity Test
Compartment Syndrome Incident
Facilitated Learning Analysis
Mark Twain National Forest
June 2013
Work Capacity Test • Compartment Syndrome Incident • Facilitated Learning Analysis
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“The Facilitated Learning Analysis process helps us to
maximize learning opportunities presented by unintended
outcomes or near miss events. The intent is to improve
performance by generating individual, unit, and
organizational learning that capitalizes on shared
experience—blaming is replaced by learning.”
Facilitated Learning Analysis
Implementation Guide
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Contents
I. Leader’s Intent…..………………………………………………….……….… 4
2. Sequence of Events………………………………….………….……..……. 5
3. Lessons Learned from Participants…………………...……..…………..… 10
4. Recommendations……………………………………………………………. 11
5. Commendations…………………………………..……………..….……..…. 11
6. Facilitated Learning Analysis Team……………………….……………..… 12
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I. Leader’s Intent
This Work Capacity Test “Compartment Syndrome” Incident occurred on February 6, 2013 on
the Mark Twain National Forest. [See “Compartment Syndrome” definition on page 8.]
On February 11, 2013, Forest Supervisor William B. Nightingale elected to conduct a Facilitated
Learning Analysis (FLA) of the incident, the employee’s treatment, and outcomes.
The Forest Supervisor’s Delegation of Authority directed the FLA Team to produce a report that:
Conveys key aspects of the incident, lessons learned, and recommendations for others
to consider in administering the Work Capacity Test—or when faced with a potential
Compartment Syndrome event.
In the spirit of a learning culture, builds upon the learning associated with a similar
incident that occurred on the Chequamegon-Nicolet National Forest on September 9,
2011 [http://wildfirelessons.net/documents/Compartment_Syndrome_Rhabdo_FLA.pdf].
Validates the facts and medical outcome of the incident.
Explores the use of virtual meetings and Video Teleconferencing Equipment (VTC)
where appropriate.
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2. Sequence of Events
On February 12, 2013, two FLA Team members interviewed—by telephone—the employee
who was injured during the Work Capacity Test. The FLA Team also spoke with the
employee’s fiancé.
On February 27, 2013, three FLA Team members met with the Work Capacity Test
administrators and personnel from the Mark Twain National Forest fire management staff to
discuss the events surrounding the February 6, 2013 Work Capacity Test.
Wednesday, Feb. 6 – Pack Test
The Work Capacity Test site was a local school’s ¼ mile track. The administrator and
administrator trainee arrived at approximately 9:30 a.m. Some Work Capacity Test (commonly
known as the “Pack Test”) participants were already stretching and warming up.
The day was sunny, approximately 45 degrees, with a slight breeze. The heat stress factor was
deemed to be low during this period.
A total of 17 people were signed-up to take the test, two at the “moderate” level, and the
remaining 15 people at the “arduous” level.
The participants were briefed. The Job Hazard Analysis (JHA) was reviewed and signed by all
participants. No concerns were mentioned.
A local ambulance was used to provide emergency medical support during the Pack Test. Once
the ambulance arrived on scene, the administrator started the test. (The ambulance was there
for assistance but was not dedicated to the test. If it was dispatched to another call, the Pack
Test would have to be suspended.)
A fire manager who had transferred from another
region commented on the professional manner in which
the test was set-up and conducted.
Employee’s Apparent Fitness Level
Edward [not the employee’s actual name], a collateral
duty firefighter, was at the site in time to stretch.
Several employees noticed that he was in good
physical condition—with a “heavy build—body builder
type.” These employees say he “looked ready to take
the test.” (Edward had taken the Pack Test every year
since 2002. He had always passed. He remembers
having some pain in his legs after some of these Pack
Tests—never during.)
In their initial interview with Edward, the FLA Team
learned that—prior to this Pack Test—he was running
four to five miles every other day and does resistance
training (push-ups, squats, and sit-ups) on his nonrunning
days.
Work Capacity Test Definition
“Work Capacity Tests (WCT) are used to ensure that
persons assigned to fire activities are physically capable
of performing the duties of wildland firefighting and to
meet National Wildfire Coordinating Group (NWCG)
standards for wildland firefighters (Wildland Fire
Qualification Subsystem Guide 310-1, NWCG, 1993).”
“Pack Test: The Pack Test is a job-related test of the
capacity for arduous work. It consists of a 3-mile hike
with a 45-pound pack over level terrain. A time of 45
minutes, the passing score for the test, approximates an
aerobic fitness score of 45, the established standard for
wildland firefighters.”
“Arduous: Duties involve field work requiring physical
performance calling for above-average endurance and
superior conditioning. These duties may include an
occasional demand for extraordinarily strenuous
activities in emergencies under adverse environmental
conditions and over extended periods. Requirements
include running, walking, climbing, jumping, twisting,
bending, and lifting more than 50 pounds; the pace of
work typically is set by the emergency condition.”
National Wildfire Coordinating Group’s
Glossary of Wildland Fire Terminology
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Edward said that the night before the Pack Test he
had a light meal of broccoli, cheese, and rice. He
takes no vitamins or supplements and does not
regularly consume energy drinks.
On his way to the Pack Test, Edward stopped at a
store for water and a candy bar.
Pack Test Culture Discussion
The physical requirement for Wildland firefighters
demands a high level of fitness. The Work
Capacity Tests (WCT) separates firefighters from
other employees based on the WCT as a condition
of hire. Some individuals believe this division has
helped to establish a culture of accepting pain that
is potentially produced by the Pack test.
This common acceptance of pain as being part of
the Pack Test perhaps leads participants to believe
that any post-Pack Test pain or discomfort must
simply be “normal” muscle pain.
Pack Test Performance
Prior to taking the “arduous” Pack Test, Edward told
one of the lap counters that he knew how fast he
needed to go to pass. He said that he planned to not strain, just keep a steady pace.
As the Pack Test started, Edward’s earphones were tangled in his vest. He stopped to untangle
his earphones. It took approximately one minute to fix the earphones and readjust his vest.
Because he had lost a bit of time, the administrator asked Edward if he wanted to wait and start
separately. Edward declined; he wanted to continue.
Without straining, he was able to catch the rest of the group before the end of the first lap. He
set a constant pace and did not seem to be under any significant stress.
Prior to the Pack Test, Edward had wrapped his lower right leg with ice. Due to knee surgery on
his left leg in 1985, he has a very particular gait to his walk. During the Pack Test, this gait
became noticeable to others. Edward stated that this gait does not affect his physical abilities.
As Edward performed the Pack Test, he chatted with other participants and acknowledged the
lap counters as he circled the track. He said he never felt any stiffness or pain during the test.
The Mark Twain National Forest (MTNF) advises employees to bring their own water to the
Pack Test as it is not provided at the test site. Edward was new to this Forest. Previously, he
had taken the Pack Test in another Region, where he was used to water being supplied at the
track.
Post Pack Test
After the Pack Test, Edward took off his weight vest and ran one more lap and then stretched
for approximately 15 minutes. It was during this stretching that Edward began to feel pain in his
right leg’s calf area. As Edward walked back to the government vehicle, his legs were getting
stiffer. Because his leg was causing him pain, when Edward and his fellow employee left the
Pack Test site, Edward asked the other employee to drive.
They arrived back at the their Ranger District at approximately 12:30—almost two hours after
the Pack Test had been completed. Upon their arrival, Edward told the other employee that he
couldn’t put any pressure on his right leg. “When I got to the District,” Edward recalls, “I couldn’t
get out of the truck. Finally, using my left leg to get out, I lay down on the ground and stretched
for approximately 30 minutes.”
Next, when he tried to walk to the District office building, he made it as far as the outside office
door—where the pain in his leg forced him to sit for approximately ten more minutes. When he
got up and entered the building, he only made it as far as the conference room, where the pain
and inability to walk forced him to collapse onto the floor. Edward said a coworker brought him
Gatorade and two Tylenols. He said he lay there for approximately 35 minutes. He said that the
Tylenol did not alleviate his pain.
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Edward said he was finally able to make it to his desk—where he alternated doing his work and
getting up and walking around. Another employee told Edward that—based on how he was
feeling—he should go to the hospital.
Goes Home Early—Then to Hospital
Due to the continuing and escalating pain in his leg, Edward decided to go home early that day.
Because to try to bend his right leg caused him so much pain, he had to use his left leg—
operating three pedals—to drive his standard transmission vehicle home.
After Edward returned home—around 2:30 p.m.—he continued to be in pain. He took a “long,
hot” shower and put his leg on ice. “But it didn’t help,” Edward says. He took two more Tylenol.
At this point, he also noticed that his urine was very dark in color. He attributed this to being
dehydrated.
That night in bed, it was impossible to sleep. The slightest pressure on his right leg, even just
the weight of his hand, was extremely painful. Due to the severity of the pain associated with
this condition, it was difficult for Edward to walk. He says he could only “crawl around on the
floor.” He called his fiancé (who lives in another state). After consulting with his fiancé, Edward
drove himself to the hospital—once again using solely his left leg to negotiate the vehicle’s
pedals. (He drove an “automatic” transmission vehicle this time.)
At approximately 9 p.m., Edward was admitted to the Emergency Department. At first, because
they could find nothing wrong, they were about to release him. They then took a blood test
which revealed that Edward’s Creatine kinase (CK) level was 19,000. Normal levels should be
between 40 and 600. The CK level in blood tests is used as a marker of Rhabdomyolysis (see
definition on next page).
Edward was admitted to the hospital and put on an IV with saline solution. No pain medicine
was administered.
The Next Day, Thursday, Feb. 7 – At the Hospital
The next morning, a District employee received an unclear text from Edward. After a delay, they
were able to contact Edward to learn that he had been admitted to the hospital the night before.
The employees immediately notified personnel at both the District and the Supervisor’s Office.
At 2 p.m. that day, the Zone Fire Management Officer (FMO) and another employee went to the
hospital to check on Edward. At that time, as far as anyone could tell, he was still just receiving
saline solution by IV.
Edward hadn’t eaten the hospital food. The employees, therefore, went to an Arby’s and
brought him back a sandwich. They stayed at the hospital with Edward until 6 p.m.
A “heads up” email from the FMO went out over the Region’s FMO mailing list. This message
explained that an employee had been admitted to the hospital after the Pack Test. This
information spurred a response from the Regional Fuels Specialist, wondering if “Compartment
Syndrome” had been considered as Edward’s ailment. The Region 9 Safety and Occupational
Health Manager had also been notified. She cc’d an email to an employee in the Region who
had suffered through Compartment Syndrome and Rhabdomyolysis in 2011. That employee
wrote an email to the unit fire staff, explaining signs and symptoms and recommending getting a
second opinion—and the need to do so quickly.
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What is ‘Compartment Syndrome’?
“A condition that occurs when the amount of swelling and/or bleeding
in a muscle compartment causes pressure that is greater than the
capillary pressure and results in tissue ischemia (lack of oxygen) and
potential tissue death.”
From Athletic Training and Sports Medicine, 1999;
Editor: Robert C. Schenck Jr., MD
http://www.nwcg.gov/branches/pre/rmc/index.htm
What is ‘Rhabdomyolysis’?
“‘Compartment Syndrome’ can lead to ‘Rhabdomyolysis,’ the breakdown of
muscle fibers resulting in the release of muscle contents (myoglobin) into
the bloodstream. These releases can cause multiple symptoms and, if left
undiagnosed, can lead to kidney and muscle damage, and in rare cases,
results can be fatal.”
May 12, 2011, Safety Alert on Rhabdomyolysis (“Rhabdo”) sent out by the NWCG’s
Risk Management Committee: http://www.nwcg.gov/branches/pre/rmc/rhbdo_study.pdf
District employees began researching “Compartment Syndrome” on the Internet. The Zone
FMO talked with Edward and his fiancé (who had arrived from out of state). He suggested that
Edward’s injuries could be related to Compartment Syndrome.
The FMO arranged for Edward to speak on the phone with the Region 9 employee who had
been diagnosed with Compartment Syndrome and Rhabdomyolysis after also completing the
Pack Test.
Edward’s fiancé and the local employees were concerned about the level of care that Edward
was receiving at this hospital. They feared that if he was suffering from Compartment
Syndrome—to prevent other serious health consequences—there was only a small window of
time when the appropriate medical actions must be administered.
Decision Made to Transfer to Another Hospital
At approximately 7 p.m. that evening, Edward’s fiancé talked with the doctor. The decision was
made to move Edward to another hospital. Edward wasn’t transported until approximately 10
p.m. He arrived at the new hospital at 11:30 p.m.
Within an hour of his admittance, Edward was positively diagnosed with Compartment
Syndrome. Surgery preparation began. Edward was under sedation by 2:30 a.m.
Edward’s fiancé told the FLA Team that the doctor was “extremely concerned” about the
extended time period from when Edward’s pain began on Wednesday to his arrival and
Compartment Syndrome diagnosis early Saturday morning.
The surgical procedure—at 2:30 a.m.—included making three approximate nine-inch incisions
on Edward’s right leg—from his knee down to his ankle. After the surgery, the doctor told
Edward’s fiancé that, initially—due to the extended period that this condition had remained
untreated—he had been worried that Edward’s leg could require amputation. However, when he
operated, there was no dead muscle discovered in the leg.
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Monday, Feb. 11
By now, Edward’s CK level has dropped significantly. He is able to navigate on crutches. The
doctors believe that Edward could be released from the hospital under the care of a doctor near
his “care-giver” fiancé’s home. He will need to undergo physical therapy for eight weeks. At that
time, a determination will be made on his availability to return to work.
Tuesday, Feb. 12
Four days after his surgery, Edward is released from the hospital to recover and rehabilitate
under his fiancé’s care out of state.
March
By the end of March, Edward is still undergoing his eight-week physical therapy process and is
“doing better.”
May
Edward’s doctor releases him to go back to work on May 7. At that time, he starts teleworking
from out of state. His physical therapy was to wrap up the last week of May.
June
With his doctor’s permission, Edward was set to return back to work at his District office the first
week in June. For three to six months, he will be on light duty. The doctor stated that—until
further notice—Edward will be able to stand/walk for only one hour per day.
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3. Lessons Learned from Participants
Increased Compartment Syndrome Awareness
During the FLA process, several employees said that they wished they had realized
much sooner that Compartment Syndrome could be a factor. We need to raise
employee and supervisor awareness and also local health care workers’ awareness.
[Note: Since this FLA was started, a physician info sheet on Compartment Syndrome
and Rhabdomyolysis has been developed and is posted on the F&AM WCT website:
http://www.fs.fed.us/fire/safety/wct/Compartment_Syndrome_Rhadbo_Physician_Hando
ut.pdf.]
While Rhabdomyolysis (“Rhabdo”) was talked about in their fire refresher training, there
is a need to modify the Work Capacity Test’s Job Hazard Analysis (JHA) to include
Compartment Syndrome and Rhabdo. Also, consider the Work Capacity Test literature
and administrator’s guide as another place to include educational information on the
risks and symptoms of Compartment Syndrome and Rhabdo. [Note: Since this FLA was
started, the Work Capacity Test specific JHA has been updated and is posted on the
F&AM WCT website: http://www.fs.fed.us/fire/safety/wct/wct_index.html.]
Consider having an After Action Review (AAR) to discuss how people feel after taking
the Pack Test. In addition, consider keeping participants around longer to allow the test
administrators to monitor them. One thought was to have the administrator check every
participant prior to leaving the test area—and having other personnel check-up on the
participants later in the day.
Medical Facilities/ Workman’s Compensation/Advocacy
Employees need a greater awareness of OWCP processes (i.e. Workers
Compensation), the agency’s role and employee’s role, HIPAA 1 related issues, advocacy
questions, and general contact issues between the Albuquerque Service Center (ASC)
and the employee. [Note: Workers Compensation has written a document to better
facilitate these processes: Facilitating Treatment of Traumatic Injuries.]
Anecdotal Conversation between Participants – Questions to Ponder
Are personnel actually preparing for the Pack Test—or just showing up and taking it? If
one doesn’t train, is the physical impact and associated pain potentially worsened?
Are people properly preparing by practicing with a weight vest and walking? Or, due to
their normal exercise routine, are they assuming that they are already “in shape” for the
Pack Test?
Several concerns were voiced about the current Pack Test culture that makes it difficult
for someone to admit that the Pack Test “beat them.” Succeeding in the Pack Test has
become a matter of pride that makes it very difficult for someone to admit that they were
“not tough enough to complete it.”
1 The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was enacted by the U.S. Congress to protect health
insurance coverage for workers and their families. It requires the establishment of national standards for electronic health care
transactions and national identifiers for providers, health insurance plans, and employers.
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4. Recommendations
Modify the literature (brochure, administrator’s guide) to reflect the risk of Compartment
Syndrome.
Administrators should monitor participants immediately following the Pack Test. At this
time, discuss how employees are feeling, watch for signs of unusual or extreme “pains,”
discuss symptoms that could cause medical issues, ensure participants will be around
other people during the next few hours (whether employees or family). In addition,
ensure that these people are aware of the steps to take if ill health symptoms begin to
emerge in this person who has recently completed the Pack Test.
5. Commendations
The FLA Team would like to commend several of the Mark Twain National Forest employees for
their quick-thinking actions and proactive decisions regarding their efforts to assist Edward.
These individuals took the initiative to research Compartment Syndrome and relay significant
information to Edward and his fiancé.
The FLA Team is certain that if these employees had not done so, the outcome of this medical
incident could have been much more severe.
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6. Facilitated Learning Analysis Team
Hurston A. Nicholas, Team Leader
Forest Supervisor, Shawnee National Forest
Karen Vanzo, Facilitator
Safety/Occupational Health Manager, Chequamegon-Nicolet National Forest
Joe Domitrovich, Ph.D., Medical – Subject Matter Expert
Project Leader, Missoula Technology and Development Center (MTDC)
Monica Neal, Document Specialist
Forest Supervisor’s Executive Assistant, Shawnee National Forest
Tristian Fluharty, Region 9 Fire and Aviation Management – Subject Matter Expert
Fire Operations, Regional Office, Region 9
Jon Teutrine, Shawnee National Forest Fire and Aviation Management – Subject Matter Expert
Fire Management Officer, Shawnee National Forest
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