Trooper death report shows emergency preparation flaws

Vermont State Police lacked adequate first aid supplies to treat heat-induced injuries at the Ethan Allen Firing Range the day a trooper collapsed while trying out for a tactical team, Department of Labor documents show.

Several troopers on scene also failed to recognize Trooper Kyle Young, 28, of Monkton was suffering from a heat-related injury based on the symptoms he exhibited, the documents show.

The Burlington Free Press obtained almost 400 pages of documents used by the Vermont Occupational Safety and Health Administration (VOSHA) in its investigation into Young’s death through a recent public records request. The documents include training protocols, emails to VOSHA, the potential citations for Vermont State Police and interviews with the people conducting the try-out on September 17, 2015, at the firing range in Jericho.

Violation worksheets included in the documents show that Vermont State Police could have been issued citations worth a total of $6,300 for two violations — lacking ice packs on scene and lacking a written guide for using respiration equipment.

One of the citation worksheets suggests having emergency medical services on standby or on site during the tactical team physical tests. OSHA workplace safety standards typically do not require ambulance standby if others trained in first aid are on scene.

A local heat stroke expert says a number of risk factors were present the day of Young’s death. Denise Alosa, an athletic trainer, said many people do not recognize heat stroke when it occurs, so she hopes this incident helps spread awareness.

A pre-citation agreement between the Department of Public Safety and Department of Labor states that the Department of Public Safety, the agency responsible for overseeing state police operations, will not be cited or fined if it complies with certain conditions, including reviewing their policy for special team try-outs and implementing additional safeguards to address issues raised by VOSHA’s investigation. The agreement also states that the violations did not contribute to Young’s ultimate death.

Vermont State Police are in the process of reviewing their special team requirements and processes, Public Safety commissioner Keith Flynn said.

Flynn declined to answer questions for this story and referred all further inquiries directly to the state police.

Self-imposed pressure

Karl Hayden, a VOSHA occupational safety compliance officer, interviewed members of the Vermont State Police and provided a more detailed account of the events that unfolded on Sept. 17. Hayden also drew on a report by Sgt. Michael Kamerling, who was initially assigned to investigative Young's death for the state police.

Young had been the one of six troopers to take the physical test that day for two open positions on a special tactical team.

Prior to the physical test, Young had completed an oral interview.

Sgt. Hugh O’Donnell told Kamerling that Young, the last person to complete the oral portion of the test, had been sweating but that “was not unusual.”

Young then moved onto the physical test.

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Weather at the firing range was sunny and 82 degrees, with 49 percent humidity. Young was wearing a battle dress uniform with a 16-pound armor vest, boots and, during some parts, a full-face negative pressure gas mask.

Trooper Matt Johnson told Hayden that troopers taking the test are allowed to go at their own pace, and that any pressure troopers may feel is “all self-imposed.”

“No shouting or pushing to go faster on the course,” stated Hayden’s notes from the interview. The physical test is one of five portions of the overall audition for the tactical team.

That day, Young was running the course 10 minutes ahead of the previous applicants. He had completed the majority of the physical tests involved and was about 4 feet from the top of a 30-foot high sand hill which he was climbing.

Documents show that numerous candidates for the tactical team had completed the same physical test successfully, and the test had remained the same for at least the last four years, Johnson told state police investigators.

Four feet from the top of the hill – about 20 minutes into the test – Young stopped moving forward and collapsed.

‘I’m fine’

Trooper Young lay on the hill, his arms still moving in a forward motion. Trooper Johnson rushed up the hill and asked Young if he was okay.

Young said, “I’m fine, I’m good,” according to Sgt. Kamerling’s investigative report. Johnson then asked Young what was going on, and Young replied that he was tired.

Johnson called to troopers at the bottom of the hill and asked them to bring water or a PowerAid drink, neither of which were available. One trooper found a sugared gel pack and brought it to the top of the hill. Johnson attempted to squirt the pack into Young’s mouth, but the gel immediately came back out, Kamerling wrote.

Johnson later told Kamerling that he thought Young took his last breath before he gave Young the gel pack. Young did not make sounds, move, or respond to troopers around him from that point forward, Kamerling wrote.

Johnson called 911 at about 1:48 p.m. Troopers then undressed Young and attempted to resuscitate him using an automatic external defibrillator. The defibrillator went through 25 cycles in 55 minutes without giving a shock, unable to detect a heartbeat, Kamerling’s report stated.

Several people on scene, including Sgt. Charles Winn thought Young had suffered a heart attack, Kamerling wrote.

“Sgt. Winn said that he had seen heat related injuries in the past while he was serving in the military and had never seen them occur the way that they did with Tpr. Young,” Kamerling wrote.

Lt. Michael Manley, the commander of the tactical unit, told the VOSHA investigator that in the 25 years state police had trained at the Ethan Allen Firing Range, there had never been an injury that required an ambulance, according to Hayden’s notes.

At 3:10 p.m., Young would be declared dead at the University of Vermont Medical Center. Upon his arrival, his body temperature was about 108 degrees, according to Kamerling’s report. Athletic trainer Alosa said exertional heat stroke occurs when the body's core temperature is above 104 degrees.

This week, Capt. Bob Cushing, who gathered the materials sent to VOSHA for investigation, told the Burlington Free Press he is unsure why supplies such as ice packs were not on scene.

"It's one of those deals where the tactical team has been around for years and hindsight is 20/20," Cushing said. "I hate to say it like that, but that's the case. You can't predict the future."

Risk factors

Prior to beginning the test, Young and other candidates had been told by Trooper Johnson that the test was “strenuous and very difficult.” Johnson then asked the candidates if they had any medical issues, and specifically mentioned their hearts.

No one spoke up, Kamerling’s report stated.

Symptoms of exertional heat stroke come on quickly, said Alosa, the athletic trainer. This often makes the symptoms difficult to recognize, and they are sometimes mistaken for a heart attack or other ailments. The main symptoms of exertional heat stroke are confusion or mental status change and having a body core temperature higher than 104 degrees.

“People are usually in it before they realize it,” Alosa said. She later added, “We’re working hard on educating the medical community on how to recognize what it is. … There’s very few people in this state that would have ever recognized it. It’s a very specific thing.”

Alosa said she is one of those people who would recognize exertional heat stroke as a medical coordinator at the annual Burlington marathon.

Exertional heat stroke is brought on when the body is unable to dissipate the heat produced by exertion.

“It doesn’t necessarily only happen when it’s hot, but obviously hot weather is one of the risk factors,” she said. Alosa added that athletes, construction workers, and members of the military are at a high risk for exertional heat stroke, but, “sports are probably where you see it the most.”

A person suffering from heat stroke must be cooled “as quickly as possible”, Alosa said. After the person has been cooled, he or she can then be brought to the hospital.

“The longer they stay hot is indicative of the amount of damage to the tissues later on,” Alosa said.

Heat and humidity are several items in a list of risk factors that can lead to exertional heat stroke. According to Alosa, men and people who are bigger or more muscular are at a higher risk. Those who are sleep deprived or overzealous and push themselves to perform at a higher level than their personal fitness are also at a high risk.

Young’s girlfriend had told investigators that the morning of the try-out, Young had told her he was not feeling well and felt congested. His girlfriend had given him Tylonol Cold and Head medicine to help with his symptoms, according to Kamerling’s report.

Young’s girlfriend also said the trooper had been doing his own rigorous cardiovascular and strength training in the weeks leading up to the special team try-out. He had been using a tactical vest and gas mask during training since they were part of the test.

Young had also been using several pre- and post-workout dietary supplements during those weeks. Investigators believe Young had taken a supplement prior to the try-out.

Alosa said research on heat illnesses has not connected certain medicines or dietary supplements as risk factors for exertional heat stroke.

Looking toward the future 

According to OSHA workplace safety standards, state police were not required to have an ambulance on standby as long as other people who were trained in first aid are at the work site.

“The mere presence of strenuous physical activity in the workplace or on the job site does not require that rescue personnel be standing by,” said lawyer for the Department of Labor Dirk Anderson in an email this week.

Vermont State Police Maj. Walt Goodell said troopers are required to complete first aid training once per year, and training in CPR once every two years.

Learning about heat injuries is a component of the first-aid training, Goodell said. The first aid training is online and takes about an hour. Troopers then have to take and pass a test, Goodell said.

Information used by state police for their online first-aid training were contained in the VOSHA investigation documents. The document says that after completing the topic, participants should be able to “identify three types of heat-related emergencies and how they are cared for.” The document states the training takes about five minutes to complete.

When asked for an interview by the Burlington Free Press last week, state police first provided a document entitled “Implementation of Additional Safeguards during Physical Testing Procedures.” They then agreed to answer follow-up questions.

The document shows that state police intend to incorporate further training on heatstroke and heat related injuries into annual first aid training.

At testing sites for special teams, state police also intend to have an athletic trainer on site for the duration of testing, have a hydration schedule, designate a safety officer and have an emergency action plan in place for each venue. State police also plan to develop a medical screening form that candidates will be asked to fill out prior to testing, the document states.

Local emergency medical services will also be notified the training is taking place, and heat stroke treatment resources will be brought to the scene. A large “Rubbermaid style tub” or other similar container into which police can put water and ice along with a pop-up tent to provide shade are among the items that will be brought to the testing sites, the document states. Someone at the site will have to fill out a form showing that each directive was addressed.

Finally, state police will monitor the weather both prior to and on the scheduled test date.

Athletic trainer Alosa, who has been working with state police on developing the training plan, said she is pleased with the progress made by the law enforcement agency in improving its processes following Trooper Young’s death.

“Going forward, I hope other lives can be saved,” Alosa said. “From a horrible situation, good things can come out of it. I think Vermont State Police are really being proactive and they’ve really taken this to heart and want to work hard to make it right.”

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Contact Elizabeth Murray at 651-4835 or emurray@freepressmedia.com. Follow her on Twitter at www.twitter.com/LizMurraySMC.