Implications of Medical History

In June of 2009, the line of duty death investigations of four persons was published. Each had a cause of death attributed to cardiac failure. These four deaths should cause leaders and individuals in the fire service to face two powerful medical implications:

1. To provide quality staffing departments have to ensure that its members are routinely undergoing medical and physical evaluations, regardless of department type (volunteer, combination, paid).
2. To best preserve and support the individual health of its members, departments have to recognize that a significant number of its body may not be medically healthy enough to participate in fireground operations and should be justly restricted from doing so
In August 2008, a 47-year old volunteer line officer had participated in a training exercise (live burn). After a period of rehab monitoring after a training evolution, the line officer was found lying down, presumed to be sleeping. Despite CPR and ALS measures, he was pronounced dead, arteriosclerotic cardiovascular disease being the cause.

“The death certificate, completed by the Coroner, and the autopsy, completed by the Forensic Pathologist, listed “arteriosclerotic cardiovascular disease” as the cause of death and “stress at the live burn exercises” as the underlying cause. Findings from the autopsy include an acute thrombosis, severe arteriosclerotic cardiovascular disease, and cardiomegaly. Specific findings from the autopsy report are listed in Appendix A.
The Captain was 75 inches tall and weighed 300 pounds, giving him a body mass index (BMI) of 37.5. A BMI >30.0 kilograms per meters squared (kg/m2) is considered obese [CDC 2008]. The Captain’s risk factors for CAD included male gender, age over 45, high blood cholesterol, and obesity. In 2004, he was diagnosed with hyperlipidemia and was prescribed a lipid-lowering medication. In 2005 and 2006, the Captain was medically cleared by his primary care provider to participate in a physical ability test. Fire Department records did not indicate whether the Captain actually completed a physical ability test. However, he taught the fire fighting essentials class in which the physical ability test was a component. In a 2006 visit to his primary care physician for swollen feet, an ultrasound revealed no evidence of a deep vein thrombosis, an electrocardiogram (EKG) was normal, and an echocardiogram showed normal cardiac size and function. His last visit to his primary care provider was for a sinus infection 7 months before he died. He did not report heart-related symptoms (chest pain, chest pressure, angina, shortness of breath on exertion, etc.) to his physicians, his family, the Fire Department, or the Training Center.”
[1]

The victim’s department does not require any initial, annual medical evaluation; SCBA fit-testing; and SCBA medical clearance. Member’s primary care physician makes the determination of being fit for firefighting duties.
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In March 2008 a 62-year old volunteer firefighter was opening up the fire room searching for extension when he collapsed. The firefighter was removed, found to be unresponsive, not breathing and without a pulse. CPR was started. Cause of death is listed as atherosclerotic and hypertensive cardiovascular disease.

“The FF was 65 inches tall and weighed 171 pounds, giving him a body mass index (BMI) of 28.5. A BMI of 25.0 to 29.9 kilograms per meters squared is considered overweight [CDC 2008]. The FF’s risk factors for CAD included male gender, age over 45, high blood pressure, high cholesterol, and smoking. In 1985, the FF suffered a silent heart attack (diagnosed by EKG changes). In 2003, the FF was diagnosed with chronic obstructive pulmonary disease, hyperlipidemia, and hypertension. Lipid-lowering and antihypertensive blood-pressure lowering medications were prescribed. In 2004, his primary care physician recommended an imaging cardiac stress test (cardiolite), but it appears this test was not performed. In 2005, a second lipid-lowering medication was added to his prescribed medications followed by a second antihypertensive medication in 2006. In 2007, this second antihypertensive medication was discontinued but a third lipid-lowering medication was added. His blood pressure and blood lipids remained under good control with the medications. A 2007 visit to his primary care physician revealed clear, but decreased, lung sounds. He was referred to a cardiologist in 3 months for a carotid ultrasound (March 10, 2008) and a stress test (March 17, 2008), but the FF died prior to the appointments.”
[2]

The victims’ department does require an initial medical evaluation, but not an annual one. The fire commissioner reviews personal physician findings before reporting back to work, in the case of firefighting injuries. The department has no fitness program or exercise equipment; however, following this death, the department is reported to begin an annual physical ability test for all members. Those who do not pass will be placed on restricted duty, assigned functions other than firefighting operations.[3]
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In June 2008 a 50-year old firefighter had spent the morning providing instruction at a local training center. Following lunch, he helped prepare and participate in a live fire evolution, specifically leading a search lesson. Following this, and a 15-minute break, the firefighter then led a portable extinguisher evolution. All of these actions were done in weather conditions of 95-degrees Fahrenheit and 49% humidity causing a heat index of 104-degrees Fahrenheit. Following the later exercise, the firefighter complained of not feeling well and stepped out to refresh with air conditioning inside the cab of the engine being used in training. As an instructor, the firefighter decided to cancel the next evolution due to the weather and his not feeling well. Another instructor volunteered to lead the evolution, and so the firefighter inclined and took a position operating the engine being used in the evolution. After almost eight hours since the beginning of the day’s instruction, activities were concluded. Following filling the engine’s water tank, the firefighter collapsed. CPR was started and he was later pronounced dead at the local hospital.

“The autopsy, completed by the Medical Examiner, listed “congestive heart failure” as the cause of death and “severe coronary atherosclerotic disease and hypertensive heart disease” as contributing factors. Given the FF’s underlying atherosclerotic coronary artery disease (CAD), the stressful environmental conditions and the physical stress of performing fire fighting training duties triggered a heart attack or a cardiac arrhythmia, resulting in his sudden cardiac death.”
[4]

The training center is a state-accredited facility that has provided firefighting instruction. Despite a history of not having transported any students for heat related illnesses, as well as having provided means to rehab participants, the facility had no specific written means to prevent heat injury. Five times in the report, the firefighter is reported to have told one or more persons that he did not feel well. It should also be noted that despite the weather and the setting (a fire service educational institute) there was no EMS staffed unit on the scene. A BLS unit arrived eleven minutes after dispatch and met with an ALS unit, later dispatched, while enroute to the hospital.

“Medical records showed the FF had a history of hypertension dating back to 1989, but he was not prescribed an antihypertensive medication. The FF had not seen his primary care physician since 2001. Medical records did not indicate whether the FF had his blood cholesterol level checked. However, he was not prescribed cholesterol-lowering or lipid-lowering medications. The FF smoked 2–4 packs of cigarettes per day for approximately 30 years and did not exercise. His duties as an instructor at the fire training center required heavy physical exertion. The FF expressed no symptoms of angina or shortness of breath on exertion to his physician, his family, the Fire Department, or the community college.”
[5]

The department does not have initial or annual medical evaluations; no annual SCBA fit test requirement; and no SCBA medical clearance requirement. Members injured on duty must have their personal physician make the determination of fitness to return to duty. The department has a voluntary wellness program and exercise equipment is in the station.
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In September 2007, a 56-year old volunteer chief was awakened at his home by a neighbor reporting a house fire in the area. After visually confirming the fire, he returned inside to retrieve his portable radio and collapsed. CPR was performed by a relative and ALS measures followed with the arrival of an ambulance. The chief was pronounced dead at the local hospital. Coronary artery disease is listed as the cause of death.

“The Chief was 70 inches tall and weighed 230 pounds, giving him a body mass index (BMI) of 33.0. A BMI >30.0 kilograms per meters squared (kg/m2) is considered obese [CDC 2008]. The Chief had a history of noninsulin dependent diabetes mellitus, complicated by diabetic neuropathy, diabetic retinopathy, and peripheral vascular disease. He also had high blood pressure (hypertension) and high blood lipids (hypercholesterolemia and hyperlipidemia). He was prescribed three antidiabetic medications but his compliance was poor, resulting in frequently elevated blood sugar levels (Hemoglobin A1C level of 8.4%). He was prescribed one medication for his high blood cholesterol 4 months prior to his death. It is unclear if this medication was effective as no further laboratory blood tests were performed. The Chief was prescribed three antihypertensive medications which successfully controlled his blood pressure. In 2001, his left foot was amputated due to complications from diabetes. In 2004, the Chief was hospitalized for symptoms resembling a stroke. Discharge diagnoses included uncontrolled hypertension, third nerve palsy due to diabetes, Tolosa-Hunt syndrome (an ophthalmoplegia caused by nonspecific inflammation of the cavernous sinus or superior orbital fissure), noninsulin dependent (Type II) diabetes mellitus and peripheral vascular disease. The Chief also had a history of poor compliance with physician’s advice regarding office visits and medical treatment.

He followed up regularly with his podiatrist and his ophthalmologist. He did not report heart-related symptoms (chest pain, chest pressure, angina, shortness of breath on exertion, etc.) to his physicians, his family, or the Fire Department. His last EKG approximately 1 year prior to his death showed normal sinus rhythm with first-degree atrioventricular block. The Fire Department was aware of the Chief’s medical condition and restricted him from physically demanding duties.”
[6]

The department requires initial medical screenings. These are paid for by the department using a department contracted physician to determine fitness for duty. The department has SCBA fit testing, but does not require SCBA medical screening. Additionally, the department does not have a wellness program or exercise equipment.

Review
To give proof that these reports provide evidence of medical implications, we have to look at the common factors and unique factors. Two were determined to be overweight; two were determined to be obese, each according to body mass index calculations. All were affected by atherosclerotic coronary artery disease. Neither victim’s department provided annual medical screening and SCBA medical screening. Despite the excuse used by many about financial cost, each had access to a personal physician. Likewise the reports prove that each victim had seen their personal physician, even in the case of one whose last recorded visit was in 2001. While only one of the departments represented had access to municipal health programs, each had an established administration, personnel, physician relationship involving members being declared fit for duty. This relationship is the foundation for departments; volunteer especially, to begin ensuring its members have received some form of medical evaluation, even if it is not a regularly preventive program. The chronological history of each victim also provides the evidence that if diagnosed early, interventions can be made to benefit the entire department. In the case of one of the victims, his contributing medical history had been documented as far back as 23 years. In another’s history it was documented that the victim had shown poor compliance to physician’s visits and direction.

Departments can utilize personal physicians in a ‘return fit for duty’ manner to begin identifying those members who may have medical implications. In many departments the financial burdens are many; however, the first defense against medical line of duty deaths is early diagnosis. Requiring members to maintain a reasonably responsible degree of good personal health, to include yearly physical exams, is sound guidance and not at all to be considered unreasonable.

In the area of unique factors, two provide reasonable argument as well to maintain medically fit personnel. In the first, one victim had fallen while performing firefighting operations. A mayday was called and the victim was removed and transferred to EMS personnel. A department that can deploy healthy firefighters onto the fireground can operate with the reassurance that poor health may not be a great factor in having to deploy a rapid intervention crew. However, if deploying personnel with poor and or undiagnosed medical health the odds that a rapid intervention crew or additional resources will most likely be needed is greater and will need to cover more than the structure on fire.

The other unique factor is that two of these deaths occurred in an educational environment. We accept that the fireground is largely uncontrolled. In the case of training, especially live fire training, the environment is fully under our control. This control has to extend not only to the burn evolutions, but to all support functions as well. In the case of the death at the training facility personnel operated in extreme weather without EMS personnel and apparatus on hand. A BLS ambulance arrived eleven minutes after dispatch, and it took four attempts to intubate the victim. The second such death also required an ambulance to be dispatched to the training center.

The death that occurred at a house fire also has a unique factor. Although a mayday was issued and the victim was removed, the EMS personnel that attended to him had to request that law enforcement on the scene bring their oxygen to the patient. The officer’s AED was also requested. In practical training, the environment is created and controlled by us and should include measures and resources that reduce risk of injury and death. On the active fireground we work to control the environment and should at the very least provide personnel the resources needed to fully respond to maydays. If we are unwilling to require members be physically and medically fit, and we cannot provide them with to tools needed to respond to a mayday, then the mission of the department needs serious reconsideration.

Conclusion
Determining the medical implications of its members requires that a department acknowledge its potential limitations (staffing and response) as well as be better prepared to face medically caused trouble both on the fireground and the training environment. The current economy cannot be used to justify a lack of personal responsibility for members and their health. In the four examples shown, each victim had recorded interaction with a personal physician, at various degrees. Departments can begin utilizing the relationship between a member and his or her doctor, to determine its personnel weaknesses and make adjustments accordingly. These can include establishing a wellness program; enlisting state, municipal and association support; creating recruitment and retention incentives based on good health; and redefining response and mutual aid agreements to offset the loss of personnel.
[1] Medical Findings; Fire Captain Suffers Fatal Heart Attack After Conducting Live Fire Training – Pennsylvania
[2] Medical Findings; Fire Fighter Suffers Fatal Heart Attack While Fighting Residential Fire – New Jersey
[3] Ibid
[4] Summary; Fire Fighter Suffers Sudden Cardiac Death During Live Fire Training – North Carolina
[5] Medical Findings; Fire Fighter Suffers Sudden Cardiac Death During Live Fire Training – North Carolina
[6] Medical Findings; Fire Chief Suffers Fatal Heart Attack While Responding to a Structure Fire – Pennsylvania

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1 Comment

  • Shady Grove Eye Vision Care says:

    Diabetic retinopathy can be treated with a laser to seal off leaking blood vessels and inhibit the growth of new vessels. Called laser photocoagulation, this treatment is painless and takes only a few minutes.

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“To provide a point of critical thought about certain acts and events in the fire service while incorporating behavioral education and commentary in a referenced format.”

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Comments
Ed Hartin
Wanted: Honest Discernment in Our Fire Service Discussions
Excellent article Bill!
2014-10-14 12:47:14
Ron Ayotte
Complacency and Awareness: History Lessons from the Mog and Rangers
Bill.. I agree with Tony C. The situations we respond to sometimes reuire that we tune and tweak SOPs and SOGs "on the fly" in order to complete the tasks given. Fire doesn't care what is stated in our SOPs/SOGs.
2014-10-11 22:14:29
Bill Carey
Complacency and Awareness: History Lessons from the Mog and Rangers
Thanks Tony.
2014-10-06 11:06:34
Tony C.
Complacency and Awareness: History Lessons from the Mog and Rangers
A great read, Bill. I see so much of this in the fire service. I forgot to pull up my hood on the last fire and I didn't get burned. I didn't buckle my waist strap on the last fire and I didn't get tangled up. I didn't check my bottle before my last fire…
2014-10-05 15:37:05
Kelly Jernigan
A Bit of Compassion
Thank you for taking the time to write this article. It's wonderful to know others share the same compassion for animals.
2014-09-27 13:53:01
AFTDIMage
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