36 investigating cases of rhabdomyolysis


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36 investigating cases of rhabdomyolysis

  1. 1. 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)
  2. 2. New York City Department of Health & Mental Hygiene <ul><li>Investigation conducted by: </li></ul><ul><li>Caroline Bragdon, MPH (PHPS assignee with NYC DOHMHs Environmental & Occupational Disease Epi Unit) </li></ul><ul><li>Nancy Jeffery, RN, MPH (former director of EODE Unit) </li></ul>
  3. 3. Presentation Objectives <ul><li>Describe the steps of my investigation </li></ul><ul><li>Outline difficulties in conducting investigations across agencies </li></ul><ul><li>Share lessons learned about rhabdomyolysis </li></ul><ul><li>Demonstrate time & resource commitment required </li></ul>
  4. 4. EODE’s Mission <ul><li>“ To investigate and prevent environmental and occupational disease among residents and workers in NYC.” </li></ul><ul><li>EODE activities thus include: </li></ul><ul><li>$ Investigating cases and potential clusters of environmental and occupational disease; </li></ul><ul><li>$ Researching background information on environmental and occupational exposures and diseases; </li></ul><ul><li>$ Providing technical assistance to City agencies, employers, unions, community organizations and others on health effects of environmental and occupational exposures. </li></ul>
  5. 5. Background of Investigation: Early March 2002 <ul><li>On 3/19/02 the NYPD requested the DOHMH to consult on a series of hospitalizations following a Plainclothes Training Course </li></ul><ul><li>The training course was conducted from 3/13 – 3/15/02 at the Police Academy in the Murray Hill neighborhood of Manhattan </li></ul>
  6. 6. Summary of “Outbreak” <ul><li>Total of 28 officers & sergeants participated in the 3-day training course </li></ul><ul><li>10 out of 28 were hospitalized between 3/15-3/19 for rhabdomyolysis </li></ul><ul><li>Up to 11 more reported having elevated creatine kinase (CK) levels following the training </li></ul>
  7. 7. What is Rhabdomyolysis? <ul><li>Breakdown of muscle fibers with leakage of potentially toxic cellular contents into the systemic circulation </li></ul><ul><li>Subtle clinical presentation diagnosed with serum creatine kinase (CK) elevations in excess of 2-3 times the reference range </li></ul>
  8. 8. Reasons for Concern <ul><li>Rhabdomyolysis can lead to more serious complications including renal insufficiency, acute renal failure, hepatic insufficiency, cardiac arrest and compartment syndromes </li></ul><ul><li>In 1988 a MA police trainee & a FDNY trainee died of complications of rhabdomyolysis following two separate agency trainings </li></ul>
  9. 9. Background Information <ul><li>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 </li></ul><ul><li>Director of the NYPD Occupational Safety and Health Unit requested additional investigation by DOHMH </li></ul>
  10. 10. Gathering Relevant Information: Early March 2002 <ul><li>1) Literature Review: </li></ul><ul><li>Exertional Rhabdomyolysis and Acute Renal Impairment – New York City and Massachusetts, 1988 . MMWR 1990; 39(42); 751-756 </li></ul><ul><li>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 </li></ul><ul><li>Craig, S, Kreplick, LW. Rhabdomyolysis . eMedicine Journal, January 18 2002, Volume 3, Number 1 </li></ul><ul><li>Gabow PA, Kaehny WD, Kelleher SP. The Spectrum of Rhabdomyolysis . Medicine (Baltimore) 1982 May;61(3):141-52 </li></ul><ul><li>Line RL, Rust GS. Acute Exertional Rhabdomyolysis . American Family Physician 1995 Aug;52(2):502-6 </li></ul><ul><li>Sauret JM, Marinides G, Wang GK. Rhabdomyolysis. American Family Physician 2002 March 1;65(5):907-12 </li></ul>
  11. 11. Gathering Relevant Information: Early March 2002 <ul><li>2) Phone Interviews with experts: </li></ul><ul><li>Michael Pratt, MD, MPH: Physical Activity and Health Branch, Division of Nutrition & Physical Activity, CDC </li></ul><ul><li>Michael Kennedy, MD: former EIS Officer who investigated 1988 FDNY & MA Police Trainee cases </li></ul><ul><li>Rich Killingsworth, MD: UNC, Chapel Hill, EIS Officer who investigated 1998 deaths among wrestlers </li></ul><ul><li>Edward Zambraski, Ph.D: Rutgers University Hydration and Rhabdo Expert </li></ul><ul><li>Bruce Wenger, MD: US Army Performance Lab Exertional Heat Stroke Expert </li></ul>
  12. 12. Findings: Risk Factors for Rhabdomyolysis <ul><li>Inherited/genetic & metabolic disorders </li></ul><ul><li>Toxic (alcohol, drugs, other toxins) </li></ul><ul><li>Excessive muscle exercise </li></ul><ul><li>Direct muscle injury (compression, trauma) </li></ul><ul><li>Ischemic injury (vascular occlusion) </li></ul><ul><li>Viral & Bacterial Infections </li></ul><ul><li>Heat related syndromes </li></ul><ul><li>Eating certain kinds of fish (eel, pike, buffalo) </li></ul>
  13. 13. Most common risk factors for Rhabdomyolysis <ul><li>Exertional & heat stroke (untrained people undertaking vigorous exercise) </li></ul><ul><li>Crush injury & trauma (ischaemia, direct muscle injury) </li></ul><ul><li>Alcoholism </li></ul><ul><li>Drugs (both legal & illegal) </li></ul>
  14. 14. Drugs associated with Rhabdo <ul><li>Legal: diuretics, antihistamines, AZT, antidepressants, cholesterol-lowering & corticosteroids </li></ul><ul><li>Illegal: cocaine, heroin, LSD, amphetamines, MDMA, ecstasy </li></ul>
  15. 15. Findings from Phone Interviews <ul><li>Rhabdo is seen frequently among military recruits following short intense & hard endurance exercise </li></ul><ul><li>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 </li></ul><ul><li>Ideally training should be recreated with CK levels monitored throughout </li></ul>
  16. 16. Review of Training Curriculum: Late March 2002 <ul><li>3/26/02 met with Director of the Occupational Safety and Health Unit & trainers who taught the 3/13-15 training course </li></ul><ul><li>Conducted walk through of the rooms used for training with DOHMH Industrial Hygienist </li></ul><ul><li>Watched demonstrations of exercises </li></ul><ul><li>Reviewed training curriculum </li></ul><ul><li>Discussed 3/13-3/15 Plainclothes Training Course with trainers for their impression of events </li></ul>
  17. 17. Findings from Police Academy Meeting <ul><li>Environmental conditions in training rooms was appropriate (CO, temperature) </li></ul><ul><li>Officers/Sergeants report enjoying training curriculum </li></ul><ul><li>Performance in training does not impact future employment </li></ul><ul><li>Physical activity on 2 out of 3 days only </li></ul><ul><li>Training exercises did not appear to be strenuous aerobically, however, kicking, punching, falling and cuffing was involved </li></ul>
  18. 18. Description of Training Participants <ul><li>Majority of training participants were from the 6 th precinct in Greenwich Village (prostitution/anti-crime) </li></ul><ul><li>Participants were seasoned officers with many years on the force </li></ul><ul><li>No physical activity requirement at NYPD, many unused to exercise </li></ul><ul><li>Many officers typically worked night shift </li></ul>
  19. 19. Related to WTC? <ul><li>Heightened awareness of health status of NYPD following 9/11 </li></ul><ul><li>First training conducted since training was suspended following 9/11 </li></ul><ul><li>NYPD may have been working increased hours, atypical shifts, & engaged in unfamiliar activities </li></ul>
  20. 20. Next Steps: Early April 2002 <ul><li>Develop questionnaire for trainees </li></ul><ul><li>Develop medical chart abstraction form </li></ul><ul><li>Meet with NYPD Supervising Chief Surgeon </li></ul><ul><li>Discuss plans with Unions (PBA & SBA) </li></ul><ul><li>Gain input/approval for questionnaire from DOHMH, NYPD & Unions </li></ul>
  21. 21. Questionnaire Development <ul><li>15 Page Questionnaire assessing: </li></ul><ul><li>Physical Fitness & Exercise Habits </li></ul><ul><li>Underlying Medical Conditions </li></ul><ul><li>Hydration/Diet pre/post & during course </li></ul><ul><li>Activities pre/post & during course </li></ul><ul><li>Drug & Alcohol Behavior </li></ul><ul><li>Prescription drug medication </li></ul><ul><li>Recent viral/bacterial illness </li></ul>
  22. 22. Barriers to Investigation: Why the Questionnaire was dropped <ul><li>SBA/PBA & NYPD all resistant to questions that would indicate culpability </li></ul><ul><li>Drug/alcohol & certain infectious disease questions likely left blank </li></ul><ul><li>Desire to collaborate with unions/NYPD conflicted with need to conduct science-based investigation </li></ul><ul><li>Bottom Line: Recommendations were likely to be the same regardless of findings </li></ul>
  23. 23. Medical Chart Abstraction Form <ul><li>No standard in existence: thus borrowed outline from injury surveillance abstraction form for workers at WTC site </li></ul><ul><li>Collaboration with Integrated Surveillance team to fine-tune form </li></ul><ul><li>Multiple drafts reviewed by staff from both agencies, physicians & nurses prior to pilot test & implementation </li></ul>
  24. 24. Next Steps: April 2002 <ul><li>Medical Chart Review with Integrated Surveillance Staff </li></ul><ul><li>10 Charts, 5 hospitals, 3 counties </li></ul><ul><li>8 charts in 3 NYC hospitals </li></ul><ul><li>2 charts outside city jurisdiction </li></ul>
  25. 25. Medical Chart Review Findings: Summary of Ten Hospitalized <ul><li>Age range 33 – 43 years old, average age of 36 years </li></ul><ul><li>8 male, 2 female </li></ul><ul><li>5 smokers </li></ul><ul><li>8 prostitution/anti-crime cops from 6 th precinct (all male) </li></ul><ul><li>All walk-in, 2 on 3/15, 1 on 3/16 and remaining 7 on 3/18-3/19 </li></ul>
  26. 26. Medical Chart Review Findings <ul><li>CK levels 4,390 - 118,882 units per liter (normal: 60 – 200 units per liter) </li></ul><ul><li>Primary diagnoses: rhabdomyolysis </li></ul><ul><li>Secondary diagnosis: diffuse myalgias; disorders of muscle, ligament or fascia; or, tendonitis, myositis, and bursitis </li></ul><ul><li>6 had dark or tea colored urine </li></ul><ul><li>No tox screens but negative history </li></ul><ul><li>White blood cell counts were within acceptable ranges </li></ul>
  27. 27. Medical Chart Review Findings <ul><li>5 hospitalized < 1 day </li></ul><ul><li>5 hospitalized 4-10 days </li></ul><ul><li>Of those hospitalized > 1 day: 2 had underlying conditions unrelated to the training which required follow-up and hospital care </li></ul><ul><li>All received IV fluids, responded well to treatment, decreased CK levels over time </li></ul>
  28. 28. Findings of interest <ul><li>All 10 indicated that the activity preceding the onset of their chief complaint was a rigorous or strenuous training exercise at the police academy </li></ul><ul><li>8 also reported being told by their Commanding Officer to report to hospital after learning that other officers from the training had been hospitalized </li></ul>
  29. 29. Conclusions <ul><li>Difficult to conclude whether training differed in any significant way from previous trainings </li></ul><ul><li>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 </li></ul><ul><li>CO’s orders may have revealed elevated CK levels that had always occurred following training exercises at the police academy </li></ul>
  30. 30. Further Conclusions <ul><li>Those unaccustomed to strenuous physical exercise are specifically vulnerable to rhabdomyolysis </li></ul><ul><li>No physical activity requirement at NYPD & activity declines with age </li></ul><ul><li>Smoking, Overweight, Diabetes, Hypertension revealed in charts </li></ul>
  31. 31. Final Steps: May 2002 <ul><li>Final Meeting with NYPD on May 7 </li></ul><ul><li>Preliminary summary of chart review findings (7 completed) </li></ul><ul><li>Written report with recommendations sufficient to re-institute the Plainclothes training course at the Police Academy </li></ul><ul><li>Discussion of ways to avoid future cases (diplomatic recommendations) </li></ul>
  32. 32. Recommendations <ul><li>Provide info packets prior to training </li></ul><ul><li>Urge candidates to avoid beverages that act as diuretics (caffeine/alcohol) & drug use 24-hours prior to the training </li></ul><ul><li>Re-schedule training in the event of a viral or bacterial illness </li></ul><ul><li>Require medical clearance for those with underlying chronic conditions </li></ul><ul><li>Monitor the ambient environment of rooms </li></ul><ul><li>Maintain adequate hydration by providing water and hydration beverages </li></ul><ul><li>Remind officers of the need to maintain physical fitness by engaging in regular physical activity </li></ul>
  33. 33. Final Timeline <ul><li>Training: March 13 –15 </li></ul><ul><li>Hospitalizations: March 15 – 19 </li></ul><ul><li>Info Gathering: March 19 – 25 </li></ul><ul><li>Tool Development: March 25 – April 18 </li></ul><ul><li>Chart Review: April 18 – May 18 </li></ul><ul><li>Final Meeting with NYPD: May 7 </li></ul><ul><li>Summary Report: Completed in June </li></ul><ul><li>Final Report: Approval still pending </li></ul>
  34. 34. Inter-agency Lessons Learned <ul><li>Vocabulary, culture, concerns & objectives different between NYPD, Unions & DOHMH </li></ul><ul><li>Changes in administration a hindrance </li></ul><ul><li>Each agency has its own review process & hierarchy which takes time </li></ul><ul><li>Collaboration means that you must compromise, but that is OK </li></ul>
  35. 35. Final Summary <ul><li>Report writing, review & finalization process took longer than investigation itself </li></ul><ul><li>Significant staff time & resources dedicated to investigation </li></ul><ul><li>Heightened awareness following 9/11 may be a drain on agency resources (other examples include school rashes, postal worker deaths) </li></ul><ul><li>Good working relationship established with NYPD </li></ul>