# Presentation: 894292

## InvestigatingCases of Rhabdomyolysis

**Following a March, 2002 **
**New York Police Academy Training Course**
**(Presented by Caroline Bragdon, MPH: **
**PHPS Grand Rounds, 9/30/2002)**

## New York City Department of Health & Mental Hygiene	

- Investigation conducted by:
- Caroline Bragdon, MPH (PHPS assignee with NYC DOHMHs Environmental & Occupational Disease Epi Unit)
- Nancy Jeffery, RN, MPH (former director of EODE Unit)

## Presentation Objectives

- Describe the steps of my investigation
- Outline difficulties in conducting investigations across agencies
- Share lessons learned about rhabdomyolysis
- Demonstrate time & resource commitment required

## EODE’s Mission

- 	“To investigate and prevent environmental and occupational disease among residents and workers in NYC.”
- EODE activities thus include:
- $	Investigating cases and potential clusters of environmental 	and occupational disease;
- $	Researching background information on environmental and 	occupational exposures and diseases;
- $	Providing technical assistance to City agencies, employers, 	unions, community organizations and others on health 	effects of environmental and occupational exposures.

## Background of Investigation: Early March 2002

- On 3/19/02 the NYPD requested the DOHMH to consult on a series of hospitalizations following a Plainclothes Training Course
- The training course was conducted from 3/13 – 3/15/02 at the Police Academy in the Murray Hill neighborhood of Manhattan

## Summary of “Outbreak”

- Total of 28 officers & sergeants participated in the 3-day training course
- 10 out of 28 were hospitalized between 3/15-3/19 for rhabdomyolysis
- Up to 11 more reported having elevated creatine kinase (CK) levels following the training

## What is Rhabdomyolysis?

- Breakdown of muscle fibers with leakage of potentially toxic cellular contents into the systemic circulation
- Subtle clinical presentation diagnosed  with serum creatine kinase (CK) elevations in excess of 2-3 times the reference range

## Reasons for Concern

- Rhabdomyolysis can lead to more serious complications including renal insufficiency, acute renal failure, hepatic insufficiency, cardiac arrest and compartment syndromes
- In 1988 a MA police trainee & a FDNY trainee died of complications of rhabdomyolysis following two separate agency trainings

## Background Information

- NYPD’s Supervising Chief Surgeon had concluded that based on the available information, the elevated CK levels were probably due to the physical activity involved in the training course
- Director of the NYPD Occupational Safety and Health Unit requested additional investigation by DOHMH

## Gathering Relevant Information: Early March 2002

**1)****	****Literature Review:**
- _Exertional Rhabdomyolysis and Acute Renal Impairment – New York City and Massachusetts, 1988_.  MMWR 1990; 39(42); 751-756
- _Hyperthermia and Dehydration-Related Deaths Associated with Intentional Rapid Weight Loss in Three Collegiate Wrestlers — North Carolina, Wisconsin, and Michigan, November–December 1997._  MMWR 1998; 47(6); 105-108
- Craig, S, Kreplick, LW.  _Rhabdomyolysis_.  eMedicine Journal,_ _January 18 2002, Volume 3, Number 1
- Gabow PA, Kaehny WD, Kelleher SP.  _The Spectrum of Rhabdomyolysis_.  Medicine (Baltimore) 1982 May;61(3):141-52
- Line RL, Rust GS.  _Acute Exertional Rhabdomyolysis_.  American Family Physician 1995 Aug;52(2):502-6
- Sauret JM, Marinides G, Wang GK.  _Rhabdomyolysis._**  **American Family Physician 2002 March 1;65(5):907-12

## Gathering Relevant Information: Early March 2002

**2)****	****Phone Interviews with experts:**
- Michael Pratt, MD, MPH:  Physical Activity and Health Branch, Division of Nutrition & Physical Activity, CDC
- Michael Kennedy, MD:  former EIS Officer who investigated 1988 FDNY & MA Police Trainee cases
- Rich Killingsworth, MD:  UNC, Chapel Hill,  EIS Officer who investigated 1998 deaths among wrestlers
- Edward Zambraski,  Ph.D: Rutgers University Hydration and Rhabdo Expert
- Bruce Wenger, MD: US Army Performance Lab Exertional Heat Stroke Expert

## Findings: Risk Factors for Rhabdomyolysis

- Inherited/genetic & metabolic disorders
- Toxic (alcohol, drugs, other toxins)
- Excessive muscle exercise
- Direct muscle injury (compression, trauma)
- Ischemic injury (vascular occlusion)
- Viral & Bacterial Infections
- Heat related syndromes
- Eating certain kinds of fish (eel, pike, buffalo)

## Most common risk factors for Rhabdomyolysis

- Exertional & heat stroke (untrained people undertaking vigorous exercise)
- Crush injury & trauma (ischaemia, direct muscle injury)
- Alcoholism
- Drugs (both legal & illegal)

## Drugs associated with Rhabdo

- Legal:  diuretics, antihistamines, AZT, antidepressants, cholesterol-lowering & corticosteroids
- Illegal:  cocaine, heroin, LSD, amphetamines, MDMA, ecstasy

## Findings from Phone Interviews

- Rhabdo is seen frequently among military recruits following short intense & hard endurance exercise
- Temp of room, common illness, caffeine consumption, over-the-counter supplements, drugs & alcohol, physical fitness, hydration, diet, and possible crush injury should be assessed in interview with trainees
- Ideally training should be recreated with CK levels monitored throughout

## Review of Training Curriculum:Late March 2002

- 3/26/02 met with Director of the Occupational Safety and Health Unit & trainers who taught the 3/13-15 training course
- Conducted walk through of the rooms used for training with DOHMH Industrial Hygienist
- Watched demonstrations of exercises
- Reviewed training curriculum
- Discussed 3/13-3/15 Plainclothes Training Course with trainers for their impression of events

## Findings from Police Academy Meeting

- Environmental conditions in training rooms was appropriate (CO, temperature)
- Officers/Sergeants report enjoying training curriculum
-  Performance in training does not impact future employment
- Physical activity on 2 out of 3 days only
- Training exercises did not appear to be strenuous aerobically, however, kicking, punching, falling and cuffing was involved

## Description of Training Participants

- Majority of training participants were from the 6th precinct in Greenwich Village (prostitution/anti-crime)
- Participants were seasoned officers with many years on the force
- No physical activity requirement at NYPD, many unused to exercise
- Many officers typically worked night shift

## Related to WTC?

- Heightened awareness of health status of NYPD following 9/11
- First training conducted since training was suspended following 9/11
- NYPD may have been working increased hours, atypical shifts, & engaged in unfamiliar activities

## Next Steps: Early April 2002

- Develop questionnaire for trainees
- Develop medical chart abstraction form
- Meet with NYPD Supervising Chief Surgeon
- Discuss plans with Unions (PBA & SBA)
- Gain input/approval for questionnaire from DOHMH, NYPD & Unions

## Questionnaire Development

- 15 Page Questionnaire assessing:
- Physical Fitness & Exercise Habits
- Underlying Medical Conditions
- Hydration/Diet pre/post & during course
- Activities pre/post & during course
- Drug & Alcohol Behavior
- Prescription drug medication
- Recent viral/bacterial illness

## Barriers to Investigation:  Why the Questionnaire was dropped

- SBA/PBA & NYPD all resistant to questions that would indicate culpability
- Drug/alcohol & certain infectious disease questions likely left blank
- Desire to collaborate with unions/NYPD conflicted with need to conduct science-based investigation
- Bottom Line: Recommendations were likely to be the same regardless of findings

## Medical Chart Abstraction Form

- No standard in existence: thus borrowed outline from injury surveillance abstraction form for workers at WTC site
- Collaboration with Integrated Surveillance team to fine-tune form
- Multiple drafts reviewed by staff from both agencies, physicians & nurses prior to pilot test & implementation

## Next Steps: April 2002

- Medical Chart Review with Integrated Surveillance Staff
- 10 Charts, 5 hospitals, 3 counties
- 8 charts in 3 NYC hospitals
- 2 charts outside city jurisdiction

## Medical Chart Review Findings: Summary of Ten Hospitalized

- Age range 33 – 43 years old, average age of 36 years
- 8 male, 2 female
- 5 smokers
- 8 prostitution/anti-crime cops from 6th precinct (all male)
- All walk-in, 2 on 3/15, 1 on 3/16 and remaining 7 on 3/18-3/19

## Medical Chart Review Findings

- CK levels 4,390 - 118,882 units per liter (normal: 60 – 200 units per liter)
- Primary diagnoses: rhabdomyolysis
- Secondary diagnosis: diffuse myalgias; disorders of muscle, ligament or fascia; or, tendonitis, myositis, and bursitis
- 6 had dark or tea colored urine
- No tox screens _but_ negative history
- White blood cell counts were within acceptable ranges

## Medical Chart Review Findings

- 5 hospitalized < 1 day
- 5 hospitalized 4-10 days
- Of those hospitalized > 1 day: 2 had underlying conditions unrelated to the training which required follow-up and hospital care
- All received IV fluids, responded well to treatment, decreased CK levels over time

## Findings of interest

- All 10 indicated that the activity preceding the onset of their chief complaint was a rigorous or strenuous training exercise at the police academy
-  8 _also_ reported being told by their Commanding Officer to report to hospital _after_ learning that other officers from the training had been hospitalized

## Conclusions

- Difficult to conclude whether training differed in any significant way from previous trainings
- Previous trainings may have caused elevated CK levels and muscle soreness among trainees who may not have interpreted their symptoms as being severe enough to merit medical attention
- CO’s orders may have revealed elevated CK levels that had always occurred following training exercises at the police academy

## Further Conclusions

- Those unaccustomed to strenuous physical exercise are specifically vulnerable to rhabdomyolysis
- No physical activity requirement at NYPD & activity declines with age
- Smoking, Overweight, Diabetes, Hypertension revealed in charts

## Final Steps: May 2002

- Final Meeting with NYPD on May 7
- Preliminary summary of chart review findings (7 completed)
- Written report with recommendations sufficient to re-institute the Plainclothes training course at the Police Academy
- Discussion of ways to avoid future cases (diplomatic recommendations)

## Recommendations

- Provide info packets prior to training
- Urge candidates to avoid beverages that act as diuretics (caffeine/alcohol) & drug use 24-hours prior to the training
- Re-schedule training in the event of a viral or bacterial illness
- Require medical clearance for those with underlying chronic conditions
- Monitor the ambient environment of rooms
- Maintain adequate hydration by providing water and hydration beverages
- Remind officers of the need to maintain physical fitness by engaging in regular physical activity

## Final Timeline

- Training: March 13 –15
- Hospitalizations: March 15 – 19
- Info Gathering: March 19 – 25
- Tool Development: March 25 – April 18
- Chart Review: April 18 – May 18
- Final Meeting with NYPD: May 7
- Summary Report: Completed in June
- Final Report: Approval still pending

## Inter-agency Lessons Learned

- Vocabulary, culture, concerns & objectives different between NYPD, Unions & DOHMH
- Changes in administration a hindrance
- Each agency has its own review process & hierarchy which takes time
- Collaboration means that you must compromise, but that is OK

## Final Summary

- Report writing, review & finalization process took longer than investigation itself
- Significant staff time & resources dedicated to investigation
- Heightened awareness following 9/11 may be a drain on agency resources (other examples include school rashes, postal worker deaths)
- Good working relationship established with NYPD