2/19/16
Tactical Athlete Special Interest Group
Tactical Athletes: Physical Therapists Working with Firefighters, Law Enforcement & Military
@SPTSAPTA @SPTSTactical
Tactical Athlete Special Interest Group
#tacticalathletes
www.spts.org
Tactical Athlete Special Interest Group
Tactical Athlete Special Interest Group
@SPTSTactical
Introduction !
MAJ Rich Westrick, PT, DPT, DSc, OCS, SCS "
SIG Chair: Rich Westrick
!
Vice Chair: Chuck Rainey
!
"
"
Sports Medicine Program Coordinator, St. Luke’s Health System, Boise, ID U.S Army Veteran
Tyler Christiansen, CSCS*D, USAW, RSCC "
"
@SPTSTactical
Beverly Hills Fire Department, Beverly Hills, CA U.S. Army Reserve Physical Therapist
Kyle Sela, PT, DPT, OCS, SCS, CSCS "
!
U.S. Army-Baylor DPT Program Internship Site Director, Darnall Army Medical Center, Fort Hood, TX
Firefighter Jacob Morrow, PT, ECS, OCS "
!
Deputy Chief, Military Performance Division, U.S. Army Research Institute of Environmental Medicine, Natick, MA
MAJ Sean Suttles, PT, DPT, OCS "
www.spts.org Tactical Athlete Special Interest Group
@SPTSTactical
Director, Tactical Strength & Conditioning (TSAC) Program, NSCA, Colorado Springs, CO U.S. Army Veteran
Tactical Athlete Special Interest Group
@SPTSTactical
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2/19/16
Disclosures !
Kyle Sela " "
!
Co-founder, Movement Guides, LLC & Inventor of “Squat Guide” Co-owner, Back-to-the-Box, LLC
1.
Describe the incidence and prevalence of injuries in tactical athlete populations.
2.
Understand the physical demands of tactical athletes – similarities and differences between “traditional” athletes.
3.
Understand the impact of musculoskeletal conditions on lost duty time in the tactical athlete population.
4.
Appreciate the unique rehabilitation considerations for firefighters, law enforcement, and military tactical athletes.
5.
Understand the benefit of working relationships with TSAC professionals.
Tyler Christiansen "
!
Learning Objectives
National Strength & Conditioning Association (NSCA)
Jacob Morrow, MAJ Westrick, MAJ Suttles, "
No relevant financial relationships
Tactical Athlete Special Interest Group
@SPTSTactical
Tactical Athlete Special Interest Group
Who is the “Tactical Athlete”?
“Tactical Athlete” !
Tactical Athlete Special Interest Group
@SPTSTactical
@SPTSTactical
Who is the “Tactical Athlete”?
Tactical Athlete Special Interest Group
@SPTSTactical
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2/19/16
“Tactical Athlete” !
“Tactical Athlete”
Who is the “Tactical Athlete”? !
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A professional in an occupation involving planning and maneuvering to accomplish a purpose; who, as with the professional athlete, is obligated to maintain a certain level of Operational Physical Fitness in order to fulfill that purpose, AND who must maintain that level of fitness as a term of employment. @SPTSTactical
Tactical Athlete Special Interest Group
Tactical Athlete Special Interest Group
“Tactical Athlete” !
Scofield & Kardouni, JSCR, 2015
@SPTSTactical
Tactical Athletes!
Scofield & Kardouni, JSCR, 2015
!
Scofield & Kardouni, JSCR, 2015
• General Physical Preparedness (GPP) & fitness requirements • Technical and Tactical Skills (T/TS) • Strenuous Physical & Mental requirements
Tactical Athlete Special Interest Group
@SPTSTactical
Tactical Athlete Special Interest Group
@SPTSTactical
3
2/19/16
Tactical vs Traditional Athletes
Tactical vs Traditional Athletes !
Scofield & Kardouni, JSCR, 2015
?
Tactical Athlete Special Interest Group
@SPTSTactical
Why are “Tactical Athletes” important?
Tactical Athlete Special Interest Group
Tactical Athlete Special Interest Group
@SPTSTactical
“Here It’s Not A Game”
@SPTSTactical
Tactical Athlete Special Interest Group
@SPTSTactical
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2/19/16
“Here It’s Not A Game”
Who Ya Gonna Call?
>650,000 911 calls per day @SPTSTactical
Tactical Athlete Special Interest Group
150,560 “Boots on the Ground” Military in Foreign Countries
@SPTSTactical
Tactical Athlete Special Interest Group
50,000 U.S. Army Soldiers Can’t Deploy
>87% musculoskeletal injury Malish, MilMed, 2014
as of October 2015 Tactical Athlete Special Interest Group
OSD Defense Manpower Data Center @SPTSTactical
Tactical Athlete Special Interest Group
@SPTSTactical
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2/19/16
Musculoskeletal Injury Burden
Musculoskeletal Injury Burden
>63%
>51%
Lost duty time due to musculoskeletal injury
Lost duty time due to musculoskeletal injury
Rand 2011
@SPTSTactical
Tactical Athlete Special Interest Group
Jahnke 2013
Tactical Athlete Special Interest Group
The ‘envelope’ changes following MSKI
Tactical Physical Demands & Musculoskeletal Injury Preinjury
Manageable
Tactical Athlete Special Interest Group
S. Dye ‘05
@SPTSTactical
Postinjury
Excessive
@SPTSTactical
Tactical Athlete Special Interest Group
@SPTSTactical
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2/19/16
The ‘envelope’ is not the same for all Athletes
Enhanced Tactical Athlete Physical Health and Readiness Understanding the Population
Tactical Athlete B
Tactical Athlete A
MSKI Decision Aids/ Tools
Rehabilitation
Tactical Strength & Conditioning
Tactical Athlete Special Interest Group
@SPTSTactical
Tactical Athlete Special Interest Group
Enhanced Tactical Athlete Readiness
Screening for MSKI Risk
@SPTSTactical
Tactical Athletes: Physical Therapists Working with Firefighters, Law Enforcement & Military
Tactical Athlete Special Interest Group
@SPTSTactical
7
2/19/16&
Agenda& Physical&Therapists&Working&with& Military&Tac;cal&Athletes& & CSM&2016& &MAJ&Sean&T.&SuCles&PT,&DPT,&OCS,&CSCS&
• • • • • • • • • •
Agenda& • • • • •
Military&Model&of&Orthopedic&Care& Echelon&of&Care& Treatment&and&Preven;on& Summary& Ques;ons&
Introduc;on& Disclosures& Epidemiology& Financial&Burden& Injury&Details& Tac;cal&Athlete&Defined& Why&the&Term&Fits& Who&is&The&Military&Tac;cal&Athlete?& Why&the&Term&is&Problema;c& Sports&Medicine&Model&
Introduc;on& • • • • • • •
27yrs&TIS;&17&enlisted;&10&officer& 15yrs&Green&Beret& 17yrs&airborne&status& Staff&PT&in&Lg&Med&Cen&OP&PT&clinic& Stryker&BCT&PT& Special&Forces&PT& Sports&Medicine&Fellow&NFL&(NY&Giants)&
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2/19/16&
Disclosures& • The&Author&is&an&employee&of&the&federal&gov’t& and&the&views&and&opinions&expressed&in&this& presenta;on&are&those&of&the&author&and&do& not&reflect&the&views&or&official&policies&of&the& Dept.&of&the&Army,&The&Dept.&of&Defense,&or& the&U.S.&Government.& • Dept.&of&Orthopaedics&and&Rehabilita;on,&Carl& R.&Darnall&Army&Medical&Center,&36000&Darnall& Loop,&Fort&Hood,&TX&76544,&USA&
Epidemiology& • Takehome:& • MSK&Injury&is&third&leading&cause&of:& – Total&Medical&Encounters& – Hospital&Bed&Stays& – Lost&Duty&Time&
• #1&cause&of&NBI&evacua;ons&from&OIF/OEF:& – Sports/PT&related&MSK&Injury&
Other,&0.46%&
Injury&Details& Th p ic&S ac or
• Most&Commonly&Injured&Regions&Seen&by&PT&in& Units:& Lumbar&Spine,&21.44%&
%& 31 &4. e,
Leg ,&4.6 1% &
in
– $548&million&annually&in&direct&medical&costs& – MSK&injury&is/primary&injury&type&associated& with&VA&disability&payouts&–&BILLIONS'
2%& and,&2.5 Wrist/H & .61% w,&2 Elbo %& .72 h,&2 Thig
Financial&Burden& • Takehome:&
Forearm,&0.21%&
Arm,&0.66%&
Hip,&4 .82%&
Cervical&Spine,&5.92%&
Knee,&17.98%&
Ankle/Foot,&14.32%&
Shoulder,&17.41%&
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2/19/16&
m Co aining cal Tr % Physi R3), 2.30 ity, tiv (THO Ac ary ilit 3% n-M 2.6 No
Combat - Battle Injury, 2.02%
MVA, 1.68% Training - Fastrope, 0.55%
Road&Marching,& Injury&Details& 3%&
Injury&Details&
Total'Individuals'Treated'(18'series'vs.'all'others;'n=470)' Total'Injuries'Treated'(18'series'vs.'all'others;'n=543)'
bati
Co m b In at ju N ry, o 2.7 n-B 5% att le
ves
Sports,&9%& , 2.3
5%
• Most&Common&MOI’s&for&MSK&Injuries:& Un kn
ow
Physical Training (Individual), 19.79%
n, 3
.43 PT&(other),&12%& %
Training - Field Exercise, 3.63%
• Occupa;ons& – Amaroso,&1997& all&others&
Other, 4.64% Gradual Onset, 13.63%
Running,&76%&
Training - Schools, 5.14%
Recreational Sports, 6.45% Physical Training (Unit), 11.54%
Training - Airborne Operations, 8.43%
Insidious Onset, 9.04%
Tac;cal&Athlete&Defined& • Tac;cal&defined:&& – of,&rela;ng&to,&or&used&for&a&specific&plan&that&is& created&to&achieve&a∥cular&goal&in&war,& poli;cs,&etc.&(Webster’s)& – rela;ng&to∾ons&occurring&at&the&baClefront&to& gain&a&military&end&&
18&series& (49.79%)&
18&series& all&others& • (50.21%)& The&men&in&MOS&11B&(Infantrymen)&have&the&highest& 50%& (50.64%)& (49.36%)& hospitaliza;on&rates&for&both´&injuries&and& 50%& 51%& 49%& musculoskeletal&condi;ons.&& • For&women,&the&highest&rate&of&musculoskeletal& hospitaliza;ons&was&among&Lightqwheeled&Vehicle& Mechanics,&MOS&63B&& • Detailed&occupa;on&specific&physical&demand&analysis& beyond&the&scope&of&this&20min&talk.&
Tac;cal&Athlete&Defined& • Athlete&defined:& – a&person&who&is&trained&or&skilled&in&exercises,& sports,&or&games&requiring&physical&strength,& agility,&or&stamina&(Webster)&
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Tac;cal&Athlete&Defined& • What&is&a&Tac;cal&Athlete?& – Any&professional&in&an&occupa;on&involving& planning&and&maneuvering&to&accomplish&a& purpose;&who,&as&with&the&professional&athlete,&is& obligated&to&maintain&a&certain&level&of& Opera;onal&Physical&Fitness&in&order&to&fulfill&that& purpose,&AND&who&must&maintain&that&level&of& fitness&as&a&term&of&employment.&&
Why&the&Term&Fits& • Jus;fica;on&for&use&of&the&term,&“Military&Tac;cal& Athlete”:& – Majority&of&MSK&injuries&experienced&by&military& service&members&are&related&to∥cipa;on&in&sports,& recrea;on,&and&physical&training& – Military&members&as&a&whole&are&at&substan;ally& increased&risk&for&MSK&injuries&commonly&seen&in& sports&athletes&and&managed&in&sports&medicine& clinics&compared&to&general&popula;on.&&
Tac;cal&Athlete&Defined& – Tac;cal&Athlete& – Key&term:& – Opera;onal&Physical&Fitness&& – (strength,&power,&agility,&&&stamina&to&operate& successfully&within&a&given&occupa;onal¶digm)& – Occupa;onal&tasks&+&Physical&Fitness&required&for& maneuvering&vs.&Occupa;onal&tasks&alone&
Why&the&Term&Fits& • Further&jus;fica;on&for&use&of&the&term,& “Military&Tac;cal&Athlete”:& – Army'physical'readiness'is'the'ability'to'meet'the' physical'demands'of'any'combat'or'duty' situaJon,'accomplish'the'mission'and'sJll'have'a' reserve'of'strength.'(FM'25P101,'Training&the& Force,&BaCleqFocused&Training)&&
& &&&&(Cameron,&2014)&
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2/19/16&
Why&the&Term&Fits& • Further&jus;fica;on&for&the&use&of&the&term,&“Military&Tac;cal& Athlete”:&
– “Military&leaders&have&always&recognized&that&the&effec;veness&of& figh;ng&men&depends&to&a&large°ree&upon&their&physical&condi;on.& War&places&a&great&premium&upon&the&strength,&stamina,&agility,&and& coordina;on&of&the&soldier&because&victory&and&his&life&are&so&owen& dependent&upon&them.&To&march&long&distances&with&full&pack,& weapons,&and&ammuni;on&through&rugged&country&and&to&fight& effec;vely&upon&arriving&at&the&area&of&combat;&to&drive&fastqmoving& tanks&and&motor&vehicles&over&rough&terrain;&to&make&assaults&and&to& run&and&crawl&for&long&distances,&to&jump&into&and&out&of&foxholes,& craters,&and&trenches,&and&over&obstacles;&to&liw&and&carry&heavy& objects;&to&keep&going&for&many&hours&without&sleep&or&rest&–&all&these& ac;vi;es&of&warfare&and&many&others&require&superbly&condi;oned& troops.”&(FM&21q20,&Physical&Training,&January&1946)&&
Who&is&the&Military&Tac;cal&Athlete?& • Navy:&& – Seals&& – SBU’s&
• Airforce:&& – Pararescue&(PJ’s)&& – Combat&Controller&(CCT)&
Who&is&the&Military&Tac;cal&Athlete?& • Special&Opera;ons&(closest&resemblance&to&elite& athlete):& – Recruited&from&top&2%&of&military& – Special&vexng&
• Higher&APFT&requirements&at&entrance&level& • Higher&marksmanship&requirements& • Higher&intelligence&requirements&(minimum&ASVAB>&score& 110)& • Greater&psychological&hardiness&(Bartone)& • Greater&self&efficacy&(Bartone)& • Embedded&mul;qd&performance/medical&staff&(RAND,& SuCles,&Goss)&
Who&is&the&Military&Tac;cal&Athlete?& • Army:& – Delta& – Special&Forces& – Rangers& – Special&Opera;on&Avia;on&Regiment&(SOAR)& – Special&Warfare&Center&and&School&(SWCS)&
• Marines:&& – Recon&
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Who&is&the&Military&Tac;cal&Athlete?& • US&Army&Special&Opera;ons&Command& (USASOC)&Combined&Aggregate:& – Mean&age:&&
Who&is&the&Military&Tac;cal&Athlete?& • Conven;onal&Military& – More&difficult&to&define&than&in&SOF& – Ac;ve&Duty&All&Branches&(Cameron,&2014)& • 1.4&million&AD;&enlisted:officer&5:1& • 50%&of&enlisted&≤&25y/o& • 70%&≤&30y/o& • 85.5%&male&
• Overall&(SOF,&Ranger,&SOAR,&SWCS&combined):&31.1& • 18&series&(Special&Forces):&33.7& • Non&18&series&assigned&to&USASOC&units:&29.9&
– Mean&yrs&TIS:&6.6& – Mean&yrs&;me&in&SOF:&3.7&
Military&Tac;cal…..Athlete?&
&
(Cameron,&2014)&
Why&the&Term&is&Problema;c& • Key&differences&between&pro&athletes&and& military&personnel:& – Gene;c/biomechanical&preqdisposi;on& – Specificist&vs.&Generalist& – Sports&medicine&model&vs.&Orthopedic&care&for& athletes&
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Why&the&Term&is&Problema;c& • No&professional&coaches&in&the&ranks& – Those&who&run&PRT&lack&educa;on&or&exper;se& • Everyone&thinks&they’re&an&expert&on&adult&fitness& • Shake&and&bake&training&(MFT)& • SME’s&(see&one,&do&one,&teach&one)&
– PRT&has&to&be&performed&as&a&group& • No&;me&or&personnel&to&conduct&personalized& assessments&or&develop&individualized&exercise& progressions&
Sports&Medicine&Model& • Sports&medicine&model&of&care:& – Mul;qD&
• First&responder&thru&surgeon&+&referral&specialists&in&house& • All&lanes&involved&throughout&echelon&of&care& • Physician/Ortho&Surgeon&at&point&of&injury&
VS.&
– Need&for&PT&as&MSK&diagnos;cian&minimal&
• Immediate&or&same&day&access&to&advanced&imaging& • Priori;za;on/Alloca;on&of&care&(starter&vs.&nonqstarters)& – Related&to&$$$$&invested&in&the&athlete& » Combat&vs.&combat&support&special;es?& » SOF&vs.&conven;onal&forces?& » Dependents?& » Re;rees?&
Why&the&Term&is&Problema;c& • Two&key&factors&that&significantly&impact&HPO& as&IP:& – No&season& • Periodiza;on&is&an&impossible&pipe&dream&(OPTEMPO)& • Training&monotony&& • No&off&season&
– Exposure&to&physical&demand& • IntermiCent& • Unpredictable&
Sports&Medicine&Model& – Sports&medicine&model&of&care:& • Owen&biased&toward&early&as&possible&surgery&vs.&focus& on&early&rehab& – Favors&rapid&return&to&physical&performance&(return&to&play)& over&longterm&func;onal&outcomes&
• Rehab&conducted&oneqonqone& • Rehab&includes&in&house:& – Rehab&to&performance&bridging& – “Return&to&play”/”Prepare&to&play”&performance&progression& u;lizing&sport&specific&tasks,&loads,&volumes,&and&sexngs&
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Sports&Medine&Model& – Sports&medicine&model&of&care&cont’d:& • Training&room&(career&sparing)&opera;ons& – Daily&management&of&chronic&condi;ons& – Immediate&and&daily&management&for&minor&injuries¬& requiring&an&appointment&with&a&provider& – Walkqin&availability&of&recovery&procedures& » Ice&&&compression& » Contrast&tubs& » Foam&rolling& » Compression&(eg.&Normatec&pants)& » Sow&;ssue&mobes/manual&stretching& » Heat&packs&
Military&model&of&Orthopedic&Care& – Provider&finally&refers&soldier&to&PT& • Soldier&waits&another&2q4&week&to&be&evaluated& • Soldier&now&chronically&s;ff&and&painful&
– Soldier&receives&HEP&due&to&accessibility&issues&or& receives&biw&therex&in&clinc& – Soldier&fails&to&progress&awer&6wks&and&is& discharged;&referred&back&to&PCM&for&permanent& profile& – If&lucky&the&PT&orders&imaging&to&r/o&fracture&or& ligamentous&injury&
Military&model&of&Orthopedic&Care& • Typical&ankle&sprain&case& – Report&to&sick&call&and&sit&for&several&hours&while& ankle&baloons&up& – Provided&limited&duty&profile&and&NSAIDs&w/o&f/u& care&planned& • Worse&case:&soldier&is&seen&by&an&unskilled&provider& who&immobilizes&them&
– Soldier&receives&no&rehab&for&a&month&and&doesn’t& get&beCer&
Military&model&of&Orthopedic&Care& – If&there&are&imaging&findings&soldier&receives& rou;ne&referral&to&ortho&or&podietry& – Awer&wai;ng&2q4&weeks&Soldier&is&screened&by& ortho&service&PA& – Soldier&waits&another&2q4&weeks&to&consult&with& surgeon& – Soldier&receives&surgery&for&ligamentous&rupture& one&month&later&(Soldier&is&now&2q4&months&post& original&injury)&
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Echelon&of&Care&
Treatment&&&Preven;on&for&Military& Tac;cal&Athletes& • Occupa;on/”Sportqspecific”&rehabilita;on& focus&(Infantry,&Armor,&Support,&etc)& – Regardless&of&their&specialty&the&process&is&the& same& – You&always&treat&the&impairments&you&find&and&try& as&best&as&you&can&to&keep&your&processes&within& the&context&the&pa;ent&works&in& &
Treatment&&&Preven;on&for&Military& Tac;cal&Athletes& • “Finishing&Rehab”& – Restoring&func;on&and&returning&to&preqinjury& level&of&capability&is&likely¬&enough&for& preven;on&of&subsequent&injury&(Wilk&JOSPT&14)&
Treatment&&&Preven;on&for&Military& Tac;cal&Athletes& • Determining&“Return&to&Duty”& – Understanding&physical&demands& – Running& – Comba;ves,&handqtoqhand/MMA&
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Summary& • Athlete&is&an&assump;on&in&many&cases&
– We&have&to&decide&who&in&our&popula;on&are&the& “Tac;cal&Athletes”&and&who&are¬& – Many&MOS’s&have&lower&physical&demands&and&can& tolerate&limited&physical&capability& – Permanent&limited&duty&profiling&will&bar&combat&arms& MOS&soldiers&from&con;nuing&to&serve& – Care&on&all&fronts&should&be&priori;zed&to&combat& arms&soldiers&for&that&reason&
• As&many&visits&generated&by&nonqathle;c,&nonq combat&arms&soldiers&as&combat&arms&soldiers&
Summary& • Sports&medicine&model&a&must&in&order&to& properly&care&for&tac;cal&athletes&as&if&they&are& athletes&
– Training&room&sexng&w/daily&recovery&and&“career& sparing”&treatments&necessary&& – Full&return&to&play&rehab&workups&necessary& – Streamlined/priori;zed&access&to&surgical&consults&a& must&&
• Without&these&we&are&simply&providing& outpa;ent&orthopedic&care&to&our&soldiers&the& same&way&we&would&for&anybody&else&
Ques;ons?& &
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2/19/16
Tactical Athlete Symposium Working with Firefighters Jake Morrow MPT, ECS, OCS MAJ, SP, USAR, Evans Army Community Hospital Firefighter Truck 4C Beverly Hills Fire Department
Who are Firefighters • 1.2 million • 30,052 US Departments • 31% (345,600) Career • 69% (786, 150) Volunteer • 73% of career firefighter work in areas with population >25,000
Objectives • Who is the tactical firefighter • What do they do • What challenges do they face • How and why do they get hurt • How do they return to duty • Tactics to stay fit to fight
Who are Firefighters Age • 16-19 (3%) • 20-29 (21%) • 30-39 (28%) • 40-49 (26%) • 50-59 (16%), • 60 and over (6%)
Demographics • Male 95% • Female 5% • White 82% • African American 8% • Hispanic 10%
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What We Do
Occupational Challenges
Other?
Physical Challenges Turnouts – Coat, Pants, Helmet, Boots, Hood
• Positional challenges • Turnouts • Self contained breathing apparatus (SCBA)
• Environmental conditions
• Average 30lbs • Tools average 5-10lbs • Withstands 500 F • Modified movement patterns • Now carry tools, hose, and ladders o
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2/19/16
Physical Challenges
External Factors/Loads
• Throwing ladders - 42 - 127lbs distributed over 14’-20’
Self Contained Breathing Apparatus
• Average 35lbs • Positive pressure • Increases ventilation rate, O2 consumption, and heart rate
• Reduces tidal volume
External Factors/Loads • Charged hose line • 100’ of 1.75” hose • 12.5 gallons of water • 104lbs • Nozzle Reaction force • 30-95lbs
External Factors/Loads • Tools and equipment aloft • Rescues • Search and evac
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Physiologic Stresses
Physiologic Stresses Cardiovascular and Thermal Strain
• • • •
Core body temperature increases 2.5oF in 20 min With sustained work to over 102oF Profuse sweating Prolonged periods of near maximum heart rate
Clinical Effects
Cardiovascular and Thermal Strain
• •
Stroke volume decreases
• •
Decrease plasma volume (15% in 20 min)
High blood pressure that rapidly drops with cessation of work
Hemoconcentration causes changes in blood electrolytes and platelet aggregability
Internal Risk Factors You are most likely seeing this...
• Lee et al, 2013 • Increased VO2 30% • Rapid increase in HR • Increased RPE • Time to fatigue was 50% faster
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Internal Risk Factors • 50% between age 30-50 • BMI – 80% overweight or obese • CDC fitness recommendations