R 101338Z MAY 19
FM CNO WASHINGTON DC
INFO CNO WASHINGTON DC
PASS TO OFFICE CODES:
FM CNO WASHINGTON DC//N1//
INFO CNO WASHINGTON DC//N1//
MSGID/GENADMIN/CNO WASHINGTON DC/N1/MAY//
SUBJ/UNIVERSAL TRAINING PRECAUTIONS TO REDUCE THE RISK OF EXERCISE- RELATED
COLLAPSE AND DEATH//
NARR/REF A IS OPNAVINST 6110.1J, PHYSICAL READINESS PROGRAM.//
RMKS/1. This NAVADMIN alerts all personnel of the importance of universal
training precautions (UTP) to reduce the risk of exercise- related collapse
and death and directs modifications to reference (a), the procedures for
conducting the Navy Physical Readiness Test (PRT). Tragically, in the past
year, four Sailors have passed away during seemingly normal physical fitness
exercise. One loss is too many and it is critical that every Sailor
understands the risk factors for exercise-related death and the strategies to
minimize those risks. Commanders and key leadership personnel, including
Command Fitness Leaders (CFL), must foster an exercise culture that promotes
these UTPs, recognizes the early signs of distress and permits prompt
termination of exertional activity when clear signs of distress are present.
2. Risk factors associated with exercise-related collapse and death can be
personal, environmental or external. Personal risk factors include lack of
appropriate environmental or exercise acclimatization, dehydration, recent or
current illness, accumulated fatigue, poor baseline conditioning, a
predisposing or underlying cardiac condition, exercise-induced asthma, sickle
cell trait (SCT), excess body fat (BMI > 30) and prior poor PRT performance.
Excessive motivation, is equally important to recognize as a risk factor, as
an individual can push to work hard, while ignoring the onset of physical
signs and symptoms of distress. Environmental or external risk factors
include: exercise at altitude, high ambient temperature and humidity and
dietary supplements containing stimulants to include thermogenic and energy
shots or drinks.
3. It is critically important to recognize an emergency during training
evolutions, with a timely and accurate response. Some syndromes can result
in rapid collapse while others may slowly evolve to an initial conscious
collapse. Understanding the syndromes that can lead to exercise-related
collapse can assist in guiding treatment.
a. Sudden Cardiac Arrest (SCA). SCA from cardiovascular collapse is
generally abrupt with an immediate loss of consciousness, sometimes with
brief seizure-like movements. After confirming a lack of responsiveness and
absence of a pulse, it is critical to begin high-quality cardiopulmonary
resuscitation (CPR), deploy an Automated Electronic Defibrillator (AED) and
activate Emergency Medical Services (EMS).
b. Exertional Collapse Associated with SCT (ECAST). An ECAST victim may
have been a front runner, or off to a strong start, but will be noted
somewhere before the collapse as slowing down, falling behind and struggling.
They begin to lose smooth coordination, they evolve into an awkward running
posture and gait, with legs that may look wooden or wobbly. The victim may
complain of progressive weakness, pain, cramping or shortness of breath.
Distinct from the cramping of exercise associated muscle cramping, in ECAST,
there is generally no visible muscle twitching and the muscles do not "lock
up." The pain of muscle cramping is generally excruciating, whereas the
predominate symptom of ECAST is weakness over pain. The ECAST victim will
initially be mentally clear, before the onset of confusion and loss of
c. Exertional Heat Stroke. Heat stroke can have a similar progression
to ECAST, but the hallmark that defines heat stroke is not only an elevated
temperature, but an altered mental status.
d. Continued exertional effort in both ECAST and heat stroke will
eventually lead to collapse, that in the absence of prompt intervention can
be life threatening.
4. All personnel present during a training evolution or PRT can encourage
good performance, but should also be on guard for signs that a participant is
struggling and be ready to terminate the evolution. The Navys PRT portion of
the Physical Fitness Assessment (PFA) is intended as a measure of long-term
health and wellness not of individual athletic prowess. No one should risk
their life by pushing through life-threatening conditions during a PRT. At
the first sign of distress, conduct an initial evaluation on the participant
and determine whether to call EMS for rapid transport to a capable medical
facility. Service Members who report signs of distress described above shall
seek immediate medical attention and must be evaluated by a medical provider
prior to returning to exercise.
5. Effective immediately, commanding officers (CO) and officers-in- charge
(OIC) are encouraged to exercise a liberal Bad Day makeup PRT policy for
those impacted by any signs of distress, and allow the individual to
prioritize health safety over a score by authorizing a Bad Day makeup PRT
prior to failing or completing the event. In line with reference (a)
enclosure (2), the following guidelines pertain to Sailors who:
a. Do not complete any portion of the PRT, fail or demonstrate any early
signs of exercise distress. These Sailors are authorized, at CO or OIC
discretion, a Bad Day makeup PRT and are required to be screened by medical.
Sailors must be cleared by medical to participate in the Bad Day makeup PRT.
b. Are medically cleared. They must conduct the Bad Day makeup PRT
within 7 days from medical clearance, within 45 days of the BCA date and
within the current Navy PFA cycle.
c. Participate, but do not complete the Bad Day makeup PRT.
They must be screened by medical again, and if medically cleared (no medical
waiver), the Sailor will receive a failure for the PRT and will be enrolled
in Fitness Enhancement Program (FEP).
d. Participate in the Bad Day makeup PRT. They will have only their
final PRT scores entered in PRIMS. CFLs are no longer required to enter
initial PRT scores in PRIMS (e.g., 59:59) for Bad Day makeup PRT
6. The following UTP must be applied to all fitness tests or other training
evolutions that are expected to require at least moderate exertion (heavy
breathing but able to talk in full sentences, sweating within a few minutes
a. Allow acclimatization, outside of the new accession training
environment, giving 2 to 4 weeks, to adapt to a warmer environment or higher
altitude. The wet bulb globe temperature (WGBT) is the gold standard to
measure environmental heat stress at
devices-measure-heat-stress. Commands may rely on heat stress meters to
provide WBGT information when available.
b. Ensure progressive and graduated increases in exercise duration and
intensity to the greatest extent possible in the training environment.
c. Adhere to current guidelines for hydration, promote water consumption
when thirsty and to maintain clear or light-yellow urine color as described
at https://www.hprc- online.org/articles/hydration-basics.
d. Follow DoD guidelines for rest-work cycles as described at
e. Prior to and during exercise, avoid stimulants, alcohol, energy shots
or drinks, antihistamines, diuretics, pre-workout products, weight loss and
performance enhancing supplements.
f. After PFA testing, participants should be observed for no less than
10 minutes post exertion, during an active cool down period.
g. At the early signs of distress, provide prompt medical attention, and
when deemed necessary, transfer to an appropriate level of medical care.
7. Our Sailors are expected to maintain a high level of fitness, as part of
military readiness. Failure to do so puts the individual and unit at risk.
We must all embrace this culture of fitness while still safely applying UTP.
To minimize the risk of injury, we should all limit our activity to light
exercise the day before a graded event. If a Sailor reports poor
conditioning before an event with high exertion, efforts should be made to
provide time to acclimate to an appropriate level of exercise before the
A meaningful FEP, as outlined in reference (a), using the recommended spot
checks, is intended to do this.
8. All personnel with SCT should review the video in para 13 below.
SCT is common, present in 1 per 10-12 African Americans, 1 per 183
Hispanic/Latinos and 1 per 625 Caucasians. Because SCT disproportionately
affects African Americans, any African American who does not know their
sickle cell status should engage with medical to determine their status and
understand the risk.
9. To ensure safe conduct of physical training:
a. All CFLs, first responders, corpsmen, recruit division commanders and
supervisors should watch the first responder videos listed in para 13 below.
CFLs must understand the predisposing conditions that are risk factors for
b. All medical treatment facility providers should watch the provider
video listed in para 13 below.
c. All PRT evolutions shall be monitored by personnel trained in CPR.
d. All training evolutions (e.g., command physical training, FEP, Sailor
360, etc) involving at least moderate exercise shall occur within the
Emergency Medical Service (base or 911) response area of an ambulance
equipped with a defibrillator, oxygen and hydration.
e. Activities conducting high-risk training involving physical exertion
shall incorporate SCA, ECAST and heat stroke signs, symptoms, prevention and
response protocol, including UTP, into Core Unique Instructor Training and
instructor sustainment programs.
10. ECAST Treatment. Though formal treatment guidelines have not been
developed, National Collegiate Athletic Association (NCAA) and National
Athletic Training Association (NATA) recommend the
a. Removal from activity upon demonstration of distress
b. Administer high flow oxygen
c. Transport to an emergency department in an EMS vehicle (ideally
Advanced Life Support capable) with emergency communication to alert
providers about the potential of a profound metabolic collapse event.
11. Return to training. Medical providers should follow evidence- based
guidelines that exist for rhabdomyolysis and exertional heat injury.
Currently, there are no guidelines for SCT-related injury.
Generally, the following criteria must be met: the individual should have no
symptoms (muscle ache, fatigue, etc) normal organ function as measured by
laboratory markers, and a review by a medical professional to include
counseling on progressive return to exercise and application of the UTP.
12. Reference (a) and CFL training will be updated to incorporate these risk
factors and outline procedures for preparation, intervention and return to
exercise. In the interim, and until the Physical Activity Risk Factor
Questionnaire can also be updated, CFLs must add SCT as a risk factor to ask
PRT participants about prior to beginning each PRT.
13. Videos and other training resources are available on the Uniformed
Services Universitys Consortium for Health and Military Performance (CHAMP)
a. Videos for the warfighter with SCT, first responders, and sickle cell
awareness for medical personnel can be found at https://www.hprc-
b. Guidance on heat injury prevention and treatment can be found at
c. Guidance on supplements are available through the Department of
Defense Dietary Supplement Resource https://www.opss.org.
14. Points of contact:
a. OPNAV N17 Policy: AMCS Eric Anderson, (901)874-2210 or via e-mail at
b. BUMED: CAPT Marc Franzos, (703) 681-9085 or via email at
15. This message was developed in coordination with the Surgeon General of
the Navy, Vice Admiral F. Faison and Bureau of Medicine and Surgery Staff.
16. Released by Vice Admiral R. P. Burke, N1.//