2. Clinical Case
• 26 yo male serviceman.
• PC. Sore upper limbs and dark urine
• Past hx gastric ulcers and on losec 20mg daily.
• Did a weights session on the Monday was OK Tuesday , but had very sore and weak
upper limbs, abdominal pain on the Wed with dark urine. Seen by the medic who
found he had protein and blood in the urine, was unsure and thought he may have a
UTI , gave him analgesia then referred him the next day to clinic.
• Seen by a locum GP who found the arm pain was improving , urine was clear.
• Urine dipstick showed protein++ and blood BP 160/75.
• He diagnosed rhabdomyolysis and sent the urine to the lab and did AST and ALT, K+
and creat. and sent him home.

3. • 2 days later I was at the clinic and his results were on my desk
• ALT 691 AST 2831 GGT 22 Creat 73 EGR>60 , K= 4.8
• Urine protein 1.5g/leuc 26-50 , no RBC.
• I requested a CPK and saw the patient.
• He had not used steroids , but had a EAS protein shake prior to the weights session.
• Arms were still sore and weak but improved. He still had some abdo pain
• BP 150/70, and I thought his liver was tender.
• CPK was 233000iu/l.
He was admitted by the medical team for observation.

4. • Rhabdomyolysis
• Skeletal muscle injury releasing myoglobin, CPK LDH, AST ALT and other
intracellular contents into the plasma.
• Potential complications include Hypernatraemia, Hyperkalemia, hyperuricaemia, hypo
or hyper calcaemia, DIC , and renal failure……
• Muscle pain , limited ROM and dark urine post exercise.

10. Changes in the Age composition of the Army RF
0
200
400
600
800
1000
1200
17 - 20 21 - 24 25 - 28 29 - 32 33 - 36 37 - 40 41 - 44 45 - 48 49 - 52 53 - 56 57 - 60 61 +
31-Dec-05 31-Dec-06 31-Dec-07 31-Dec-08 31-Dec-09

11. RF DEPLOYABLE STATUS
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
110%
120%
2007 2008 2009
YEAR
PERCENTAGE
PASS TOTAL TEMP UNDEPLOYABLE PERM UNDEPLOYABLE NO GRADING

12. Annual Workplace Injuries
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
110%
120%
130%
140%
2005 2006 2007 2008 2009
Year
TypeofInjury%
0.00
10.00
20.00
30.00
40.00
1 2 3 4 5
InjuryRate%ofRF
Strength
Lower back Injuries
Lower Limb Injuries
Other Injuries
Annualised Injury Rate Compared to Total RF Strength

13. • Medical Software
• Beware the central server
• Resource training , and ongoing training
• Must have good user interface to gain credibility (instinctive)
DTP

14. ABCA
• Standards
• Publications
• Reports.
• TRAC2ES
• TCCC

15. Don’t forget the alcohol !!!

16. “An asymmetric response to an asymmetric challenge”

17. COMBAT ATHLETE

18. Military Clinical Leadership