Considering LODD Medical Information

Also see: “Is It the Job or Your Body?” The intent is not to devalue or criticize the loss but to understand that there are differing methods of determining the data being presented. These differences may influence reported statistical data.

Maybe it’s not always the guy who is in poor shape. Maybe it is the combination of existing medical history as well as physical and mental stress. One constant safety for the fire service is the annual medical evaluation. In the District of Columbia this month, a routine department stress test identified a serious health condition in a 52 year old firefighter [1]. During the test, an electrocardiogram found a problem. The firefighter was transported to Washington Health Center and underwent quintuple bypass surgery and is now recovering. An annual physical fitness program with cardiac stress testing saved the life of a firefighter. Last week a number of line of duty death reports and a line of duty injury report were released to the fire service. The four NIOSH reports each attribute the cause of death to exertion, with the nature being sudden cardiac death [2]. Two of these deaths happened in 2006, the other two in 2007.

April 2006. A 57-year old volunteer Fire Chief was found dead the morning after a department training [3]. At 73 inches tall and weighing 248 pounds, he had a calculated body mass index of 32.7, considered obese [4]. He had two conflicting stress tests; the first in 2001 used persantine instead of exercise, to increase the heart rate. The second test in 2005 used exercise (treadmill test). This test was considered positive for exercise-induced schemia base on the EKG. With one test positive and another negative, the cardiologist (in 2005) concluded the exercise stress test was negative. Seven days prior to his death he passed a medical exam for a CDL. His “death was from a plaque rupture in the coronary circulation leading to coronary thrombosis, myocardial infarction and fatal arrhythmia [5].” In his department, annual medical exams are required. There is no health/wellness program nor is there a annual physical ability test.

August 2006. A 49 year old career firefighter/EMT participating in a voluntary department physical fitness program collapses while on a treadmill [6]. At 71 inches tall and 235 pounds, he is considered obese [7]. Diagnosed with high blood cholesterol, he was on a low fat diet and prescribed lipid lowering medication. Since 1997 he had exercise stress tests. No ischemic changes were noted in his history of tests. The autopsy revealed the firefighter had evidence of an old heart attack and an enlarged heart. He also had a common risk factor (atherosclerosis) for cardiac arrest. His department has annual medical evaluations, strength and aerobic equipment in quarters, available under voluntary use. There is no annual physical ability test.

January 2007. A 47 year old career lieutenant dies after working three consecutive 24-hour shifts, responding to 22 calls. After getting off duty form his tour he proceeded to exercise at a local gym, where he collapsed while on an exercise bicycle [8]. At 6 feet tall and weighing 272 pounds, his only risk factor was obesity [9]. He had a history of atrial fibrillation diagnosed in 1997 during a department medical exam. He was taken off-duty pending a cardiac evaluation. Both his echocardiogram and his exercise stress test were reported to be normal. He returned to duty being prescribed baby aspirin. In 2001 he experienced the same problem in another annual exam. He was off-duty for two weeks and then, after additional testing, prescribed various antiarrhythmic medications. In 2004 he had a surgical procedure to control persistent atrial fibrillation. He was last seen by a personal cardiologist in 2006 and cleared for duty. His department has annual medical evaluations with a exercise stress test for firefighters over 40 years of age. Exercise equipment in the station is used voluntarily and 1 ½-hours are given to members for exercise while on duty. The lieutenant was known to exercise regularly.

June 2007. A 53 year old career engineer dies while participating in a department physical fitness program. During the program the crew had also responded to three calls. At 73 inches tall and 232 pounds, the engineer is considered obese [10]; however using the skinfold test his BMI indicated not obese [11]. Since 1992 he had a history of hypertension and was prescribed medication. His blood pressure continued to stay elevated at department medical evaluations. His blood cholesterol had been elevated since 2000 and he was prescribed a low cholesterol diet, but no medication due to his HDL ratio. In 1990 he was diagnosed with intra-abdominal/aortic lymphoma and treated with surgery and chemotherapy. In 1999 he was diagnosed with testicular cancer and treated with surgery and radiation. In 2005 he underwent surgery for prostate cancer. His department has annual medical evaluations including treadmill fitness and treadmill stress tests. Chest x-rays are conducted every other year. Physical fitness is required, either aerobic or strength training, with equipment available in the station. There is no annual physical ability test.

The “Firefighter Fatalities In The United States – 2007” report states that deaths from exertion, stress and other medical issues are the largest in the Cause of Fatal Injury or Illness. 38 out of 40 deaths were categorized as “sudden cardiac deaths”. The number accounts for close to 40% of on-duty deaths annually. Post mortem information shows that 22 of the 38 had some form of pre-existing medical condition [12]. The NFPA, IAFF, IAFC and NVFC have been continually distributing information related to firefighter health and next week will see more during the National Firefighter Health Week beginning 18 August. As with any form of citing statistics, the actual data can be difficult to digest, especially if the synthesis begins broad and then develops detailed strata. For instance, in these four recently released reports a cursory light reading can lead us to believe that each of the fallen was of “that age” and had a poor health history. Only when we read in a detailed manner do we see that each one had medical condition disclosed while participating in a department medical evaluation. We can’t say that these men didn’t know about their conditions; on the contrary we learn that each one was systematically placed off-duty for additional testing and corrective measures and subsequently placed back on-duty following a department medical evaluation. There is also data that may be considered “conflicting” to the reader. Each of the four was considered obese by the National Heart, Lung and Blood Institute standards, yet in one there is mention of defining the body mass index by the skinfold test. Using the skinfold test is reportedly a better determining tool. In one of the four, there were no autopsy or toxicology tests performed. In another, the fallen was subjected to two different tests. Does this skew the statistics in deeper detail? Probably not, but it does cause us to consider ever more what it is that kills us, medically-speaking. We know there are people in Boston asking these questions [13]. And in a time when politicians and the general public have begun to scrutinize their fire departments [14], the physical exam may be as important as the extra man on the truck.

Definitions
Cause: The action, lack of action, or circumstances that resulted directly in the fatal injury.
Nature: The medical process by which death occurred and is often referred to as cause of death on d
eath certificates and in autopsy reports.
Persantine or Dipyridamole: A drug that inhibits thrombus formation when given chronically and causes vasodilation when given at high doses over short time.
Schemia or Ischemia: A restriction in blood supply, generally due to factors in the blood vessels, with resultant damage or dysfunction of tissue.

References
1.
Stress Test Saves Firefighter. District of Columbia Fire and EMS Department, August 2008
2. NFPA 901, Uniform Coding for Fire Protection, 1981
3.
Fire Chief Suffers Sudden Cardiac Death After Strenuous Training Drill – New York. NIOSH 2008
4. National Heart, Lung and Blood Institute 2005
5. Fire Chief Suffers Sudden Cardiac Death After Strenuous Training Drill – New York. NIOSH 2008
6.
Firefighter-Emergency Medical Technician Suffers Sudden Cardiac Death During Physical Fitness Training – Nevada. NIOSH 2007
7. National Heart, Lung and Blood Institute 2005
8.
After Working Three Consecutive 24-Hour Shifts and Fighting an Extensive Structure, a 47-Year Old Career LT Suffers Sudden Cardiac Death During Physical Fitness Training – California. NIOSH 2008
9. Ibid; National Heart, Lung and Blood Institute 2008
10. National Heart, Lung and Blood Institute 2005
11.
Engineer Suffers Sudden Cardiac Death After Responding to Three Emergency Calls and Performing Physical Fitness Training – Arizona. NIOSH 2008
12.
Firefighter Fatalities In The United States – 2007. NFPA, July 2008
13.
Boston Commissioner Frustrated With Fatal Fire Probe Firehouse.com July 2008
14.
Illinois Chief Won’t Change Exercise Policy Firehouse.com August 2008

Additional Reading
NIOSH Releases Cardiac Arrest LODD Reports Firehouse.com August 2008
Take Control of Your Health During National Firefighter Health Week, August 18-22 National Volunteer Fire Council
NVFC Corner: Firefighter Health Week Radio@Firehouse.com Broadcast
Contributing Factors To Firefighter Line-Of-Duty Death In The United States. Firefighter Close Calls, February 2008/IAFF September 2006
Contributing Factors To Firefighter Line-Of-Duty Injury In Metropolitan Fire Departments In The United States.Fire Rescue 1 August 2008/IAFF August 2008

Implied Communication, Updated

The following is about a fire where there are some questions within the department regarding the strategy and tactics used. This is only about the fireground communications and not the operations themselves. Link to the fireground transmissions can be found on STATter 911 or one of the individual department websites.

Note, 6 August 2008. After having been contacted by the creator of DC Fire Feed, the source of the tape of the Six Flags fireground radio transmisisons, it should be made known that periods of “dead time”, time when no transmissions are made, have been removed from the recording. Mr. Johnson was kind enough to explain how the recording works and how the actual time is listed. The numbers I list are those from the recording, so a reader could advance the tape to a certain point for a certain transmission. In the real world, as explained by Mr. Johnson, the real time is much longer.

Statement of exterior operations. Tape time 17:26, 22 minutes after dispatch “real time”

Evacuation order. Tape time 19:26, 26 minutes after dispatch “real time”

Knowing this seems to make the communications appear worse than originally thought. Bill C.


On Wednesday evening, July 30, 2008, the Prince George’s County Fire and EMS Department was dispatched for a building fire at the Six Flags amusement park. The fire was reported in the Frightorium Haunted House, during park hours. The box alarm was unaltered and brought a preplanned response of four engines, two tower ladders, a rescue squad, three tankers, one water supply unit and one battalion chief (not counting additional career and volunteer chief officers responding). With the exception of the second-due engine, all companies initially assigned were at or above their minimum staffing levels. The structure is described by various individual department commentaries as a wood frame or heavy timber building with a metal roof. The occupancy period is limited. Since it serves as a haunted house, it is only occupied for a brief period in the fall. As companies arrived on the scene they reported heavy smoke showing, followed by fire throughout. The second-due engine (E.846) is the first (radio) to report on the scene being directed in by park staff through the employee parking lot. The dispatcher checks with the first-due engine (E.843) to confirm they know this direction and they reply that they are right behind the second-due engine [1]. Approximately two minute later a chief officer advises the dispatcher that another (?) will assume command and the previous will have the water supply. The dispatcher acknowledges this, assuming by his own question, that the chief officer is on the scene [2]. Chief 843A cuts in that they are not yet on the scene, but are still being escorted in and have heavy smoke showing. Engine 843 soon advises the need of a water supply unit since they have not laid out a supply line yet [3].

As these companies make their way further into the park, the length of a primary layout is estimated, as well as the reporting of the fourth-due engine company having arrived. Engine 818 is reported to have laid out from a hydrant approximately 1,400 feet of supply line. Someone is needed to pickup their line. Four minutes after reporting being escorted in, Engine 843 gives the first sizeup report (radio). “We just want to advise we have heavy fire throughout the building, it’s all in the cockloft, and uh, right now we’re laying out to a hydrant, we have not entered the building, everyone is out of the building.”[4]

What we know:
The first-due engine is understaffed (IC is now minus one company’s manpower)
Water supply will be an issue
Engine companies may have arrived out of order (someone need to pick up the fourth-due’s hydrant)
Not everyone came in through the employee parking lot (?)
The fire building is a loss; there is no need for rescues (or did E.843 mean all of his crew is out?)

What follows next is the beginning of announcements and a declaration of various strategies. Chief 839A asks the dispatcher to make an announcement for all units to follow the employee parking lot and service road around to where units are needed [5]. Before the announcement can be made Deputy Chief 802 requests the dispatcher announce to all units his arrival and that before any units do anything further, for all command officers to report to the building so a plan can be formulated [6]. The dispatcher, not knowing which building, has to ask. He is not answered, but instead, Deputy Chief 802 asks Chief 839A if he acknowledges this (his previous report to Communications). he does and countering his earlier request asks for the units to be at least staged. Deputy Chief 802 concurs and acknowledges writing off the building [7]. A few seconds later, a company reports having established a water supply and making entry into the building [8]. The dispatcher makes the announcement for units to follow the service road off the employee entrance [9].

What more we might know:
We may or may not follow the service road
There may be a staging area
Deputy Chief 802 might be the incident commander (or is it still Chief 839A?)
Chief officers are to report to the fire building (or maybe the maintenance shed, or the human resources building)
Command has written off the fire building
An engine company has committed themselves to an interior attack
The fire has grown

The question about “command’ is settled by the dispatcher when he asks Chief 843A if he has command or who does. Duty Chief 800 answers that Deputy Chief 802 will have “command” [10] The dispatcher then makes the announcement that Deputy Chief 802 has incident command. From the recording time of 11:20 until 15:00 we hear various unanswered, broken and answered transmissions. Two of the three tankers are requesting assignments; wagon drivers are calling for lines to be charged; the second-due tower ladder is requesting an assignment; and the due-rescue squad reports their activities on side Charlie [11].

More known:
Command is established and is busy
Additional units are approaching requesting assignments (remember the plan to stage?)
Supply lines and handlines need to be charged
A second engine company has committed to the interior attack (E.837, 15:00)
An engine company (E.833) is operating a handline from the exterior with one member
The RIC is divided between assisting the above engine company and mitigating an additional hazard on side Charlie

The fireground sectors as well as the final strategy appear to develop after an announcement from the Side Charlie Command. His request for the utility company is coupled with the only radio report of fire conditions other than the initial sizeup [12]. Six minutes after an engine company reports they are making an interior attack, Command is given reports of collapse on two of four sides. Command asks if Side Charlie needs to back out for a safer area to operate in. Charlie replies,

“I wouldn’t have anybody inside this building right now, no one, exterior only. I’ve got crews on side charlie and delta flowing water, knocking this fire down, but I’d go exterior only.“ (17:06) Side Charlie Command

“Communications to Command, are you going exterior only? Do you need an announcement?” (17:26) Dispat
cher

“That is correct; it’s been exterior from the beginning.” (17.34) Command

“Very well, stand by. All units 13710 Central Avenue at Six Flags, exterior operations only, and I also copy the need for BG and E, we’re getting them now.” Dispatcher (17:36)

The rest from this point forward is reports of lines needing to positioned and charged; plan B for the water supply (wading pool); and the need to reassign someone to Water Supply in place of Chief 839A. To comment on any of this would be wrong and is not the point of this piece at all. It is to only provoke thought about our fireground communications and expectations, stated and implied, and what can be heard in the radio transmissions.

Strategy Declared

“Chief 808 to Command, priority.” Chief 808 (19:22)
“Communications to Command, Chief 808 is calling you priority.” Dispatcher (19:26)
“808 go.” Command (19:29)
“Evacuate the building, still have crews operating inside the structure. Evacuate the building, need all apparatus drivers to sound their airhorns, everyone out.” Chief 808 (19:33)
“Command to Communications – “ Command (19:44)
- Evacuation Tones sounding – (19:46)
“All units operating 13710 Central Avenue, at Six Flags, evacuate the building. All units 13710 Central Avenue, evacuate the building.” Dispatcher (19:58)

After this, strategy and tactics appear to progress without a hitch (you decide, the fire didn’t extend and no one was killed, right?). This isn’t about why chief officers had to formulate a game plan; why one engine found a closer hydrant than all the others; or anything else specific to extinguishing the fire. This writing focuses on the “communications” of the fire attack, what you can clearly hear for yourself. It is hard for a department to learn from itself without crossing the line of Monday-morning quarterbacking each other and pointing fingers at small petty issues instead of more important ones. The fire at Six Flags should ask all of us the following about our fireground communications:

What is happening to the initial sizeup and decisions afterwards?
Who is listening to us if Command is busy or being overwhelmed?
If you’re interior and I’m exterior, how do we know that?
If I’m interior and no one knows, what will happen if I need help (mayday)?
If Command doesn’t give you clear instructions, will you choose your own course? Will you tell him?
Can companies be held up momentarily in the beginning and still be aggressive?
Do incident commanders need aides to simply monitor the radio?

At the 9:52 mark in the radio transmissions, an engine company reported making an interior attack. Command believed everyone was operating from the outside and didn’t know until 19:22, almost ten minutes later.

Radio Transmissions Referenced
1. E.846 to PSC “advise the units the escort is taking us through the employee parking.” “Copy, going through the employee parking, Engine 843?” “That’s direct, we’ll be there in about five seconds, we’re right behind them.” (04:34)
2. C.839A (?) to PSC “_____843 (or C.843A) is going to take command; I’ll establish the rural water supply.” “Okay, can you advise what you have?” (06:28)
3. E.843 to PSC “ have heavy smoke showing, on the scene in about five seconds, side alpha; definitely going to need a water supply back here, we have not dropped a line, have to layout uh – .” (06:51)
4. E.843 to Command (08:30)
5. Chief 839A to PSC (08:53)
6. Deputy Chief 802 to PSC “I am on the scene, before any other units drop any lines or do anything else; I want the command officers up near the building so we can come up with a plan.” PSC – “Which building?” (09:11)
7. “That’s affirmative, we’re not gonna save this building – ” Deputy Chief 802 to Chief 839A (09:46)
8. unknown company “ – we have an established water supply, we’re making entry into the building – “ (09:52)
9. PSC to units assigned (09:58)
10. PSC to Chief 843A “do you have command? Which chief officer has command?” “Deputy Chief 802 is on the scene, has command” Duty Chief 800 (10:23)
11. Rescue Squad 808 to Command “on side Charlie, only got one person from 33 on a line back here, we’ll be working with him, we’re also shutting down propane tanks.” (16:17)
12. Side Charlie Command to Command “I need BG and E to get out here as soon as possible, I have two main, underground transformers that are smoking, I want to have them on standby, and I do have collapse on side Charlie and Delta.” (16:37)

Additional Reading
PGFEMS Press Release
Heavy Fire From Haunted House at Six Flags, Co.839/843
Engine Goes to Six Flags, Co.818
Engine 331, 332 and The Tower Ladder to Haunted House Well off at Six Flags Amusement Park, Co.833
Squad 8, Ambulance 88, Chief 8 & 8A take in haunted house on fire, Co.808
Fire Destroys Six Flags Attraction in Maryland, Firehouse.com, WJLA
Haunted house a little scarier than imagined, STATter 911

Is it the job or your body?

The 2007 Firefighter Fatality report was released this week by the National Fire Protection Agency. 102 firefighters were killed, compared to 89 in 2006. Still the fire service maintains the traditional “100 die on average each year” average. The general numbers were reported this Spring, but the complete report shows numbers that may be surprising to some. 36 deaths were under Fireground Operations for Type of Duty. This is the fourth lowest in 10 years and the sixth lowest since the studies have begun. Exertion or stress continue to be leaders in the categories of Cause of Fatal Injury or Illness and Nature of Fatal Injury or Illness. Read further into Nature and we find that:

  • 38 victims of sudden cardiac events
  • 10 had severe arteriosclerotic heart disease
  • 5 were hypertensive
  • 4 had prior heart problems
  • 3 were diabetic

In the past 25 years, post mortem information regarding medical history available of sudden cardiac death victims revealed that 92% had prior cardiovascular problems. In 2003 the National Volunteer Fire Council launched the Heart Healthy Firefighter Program. Health screenings of 8,000 career and volunteer firefighters over a four year period revealed:

  • 37% tested had high or borderline high levels of cholesterol
  • Only 16.9% had normal blood pressure
  • 44.7% were “obese” (25% or more body fat for males, 32% or more for females)

Firefighters over the age of 60 had the greatest number of deaths caused by a sudden cardiac event. Ages 51 to 55 were the second greatest.

There is debate about the numbers used in the line of duty death reports. Not the actual counts themsleves, but how the counts are classified and how the definition of “line of duty” has changed. Some believe that the 65-year old volunteer fire-police member who has a heart attack while directing traffic shouldn’t be considered an LODD, that he really has no business being out there. That may be true, but if we take him out of the equation, what about the 45-year old career member in poor health who’s department doesn’t have a PT program? What do you do with the guy who is one Krispy Kreme away from a triple bypass?

References

Firefighter Fatalities in the United States 2007 Rita F. Fahy, Paul R. LeBlanc and Joseph L. Molis, July 2008

NVFC Heart-Healthy Firefighter Program

National Firefighter Health Week, August 18 – 22, 2008