On April 27, 2007, a 51-year-old male career Captain and a crew member drove to another city to attend high-rise incident command training. After checking into the hotel, he and the crew member went to eat dinner (2230 hours). After eating and visiting with friends, the Captain complained of not feeling well and wanted to return to the hotel. Outside the restaurant, the Captain collapsed. The crew member assessed him and found him unresponsive, with agonal breathing, and with a slow pulse. The crew member began assisted ventilation via mouth-to-mouth resuscitation. An ambulance responded and provided advanced life support, including cardiopulmonary resuscitation (CPR). Approximately 47 minutes later, despite CPR and advanced life support administered on-scene and at the hospital, the Captain died. The death certificate and the autopsy (completed by the Assistant Medical Examiner) listed “hypertensive and atherosclerotic cardiovascular disease” as the cause of death.
The NIOSH investigator offers the following recommendations to address general safety and health issues. Had these recommendations been in place prior to 2007, perhaps the Captain’s sudden cardiac death could have been prevented.
INTRODUCTION & METHODS
On April 28, 2007, a 51-year-old male Captain lost consciousness while in travel status for training. Despite CPR and advanced life support administered by a crew member, the ambulance crew, and in the emergency department, the Captain died. NIOSH was notified of this fatality on April 30, 2007, by the United States Fire Administration. On May 9, 2007, NIOSH contacted the affected Fire Department to gather additional information, and on July 26, 2007 to initiate the investigation. On September 25, 2007, a Safety and Occupational Health Specialist from the NIOSH Fire Fighter Fatality Investigation Team traveled to Texas to conduct an on-site investigation of the incident.
During the investigation, NIOSH personnel interviewed the following people:
NIOSH personnel reviewed the following documents:
RESULTS OF INVESTIGATION
Incident. On April 27, 2007, just after noon, the Captain and a crew member drove to another city to attend high-rise incident command training with other members of his Fire Department. After checking into the hotel, he learned later that afternoon that the training was cancelled. Due to the late hour of notification, the group planned to return home the next day. During telephone calls that afternoon to his wife and son, the Captain did not report any health problems or symptoms. At approximately 2230 hours, he and a crew member left the hotel via taxi to eat dinner.
After eating dinner and visiting with friends, the Captain complained of “not feeling well, having cold sweats, and wanted to return to the hotel” (approximately 0034 hours). However, he remained at the restaurant for about another hour and collapsed while awaiting a taxi (0130 hours). A police officer, patrolling in the parking lot, saw the Captain collapse. Arriving at the Captain’s location, the officer noted the Captain was unresponsive, had a pale color, was sweating “uncontrollably,” and was bleeding from the nose. The Captain was rolled over on his right side and paramedics were notified.
The crew member began assisted ventilations via mouth-to-mouth resuscitation. Ambulance 506 (with a paramedic and two emergency medical technicians [EMTs]) responded, arriving at the scene at 0136 hours. Assessment revealed a pulse of 52 beats per minute and six shallow breaths per minute. The Captain was placed onto a stretcher and into Ambulance 506, where CPR was begun. A cardiac monitor was attached to the Captain, revealing asystole (no heart beat). The Captain was intubated (breathing tube inserted into the trachea), and placement was confirmed by auscultation and an end tidal carbon dioxide test. An intravenous line was placed, and cardiac resuscitation medications were administered. The ambulance departed the scene at 0153 hours, en route to the hospital; advanced life support procedures and CPR continued with no positive change in the Captain’s condition. Ambulance 506 arrived at the hospital at 0157 hours. Inside the Emergency Department, CPR and advanced life support measures continued until 0217 hours, when the Captain was pronounced dead by the attending physician.
Medical Findings. The death certificate and autopsy, completed by the Assistant Medical Examiner on April 28, 2007, listed “hypertensive and atherosclerotic cardiovascular disease” as the immediate cause of death. Pertinent findings from the autopsy included:
Positive alcohol test (0.22 grams per deciliter)
The Captain was 72” tall and weighed 237 pounds, giving him a body mass index (BMI) of 32.1. A BMI >30.0 kilograms per meters squared (kg/m2) is considered obese [National Heart Lung and Blood Institute 2005]. He had been prescribed weight control medications since 1993. The Captain was diagnosed with high blood pressure (Stage 1 hypertension) in 2000, but was not prescribed an antihypertensive medication [JNC-7 2003]. He also had a history of high blood lipids including cholesterol and was prescribed medications and low cholesterol diets. However, since 2004 his medical records did not mention on-going follow-up of his blood lipids or medications.
According to his family and crew members, the Captain had no complaints of chest pains, unusual shortness of breath on exertion, or any other heart-related illness.
DESCRIPTION OF THE FIRE DEPARTMENT
At the time of the NIOSH investigation, the Fire Department consisted of 58 uniformed personnel and served a population of 50,000 residents in a geographic area of 50 square miles. There are five fire stations. Fire fighters work the following schedule: 24-hours on-duty, 48-hours off-duty, from 0800 hours to 0800 hours.
In 2006, the Fire Department responded to 2,465 calls: 1,593 rescue/EMS calls and 872 fire/ hazardous condition calls. The day prior to the incident, the Captain performed household chores at home and drove to the training city.
Employment and Training. The Fire Department requires all new fire fighter applicants to be pre-certified fire fighters who have completed a State-licensed academy and State/National Registry EMT-Basic or higher course. In addition, applicants must pass a written test, a physical ability test, an interview board, a Chief’s interview, a physical examination, a psychological evaluation, a drug screen, and a background check prior to being hired. Newly-hired fire fighters are placed on day-shift for 1 month to learn administration, other City and County departments’ operations, dispatch, and Standard Operating Guidelines/Standard Operating Procedures/ Emergency Medical Service protocol review; then rotated to each of the five fire stations for 1 month prior to final shift placement. At each station, members must learn all aspects of that station’s operations including streets, apparatus, equipment, etc. The fire fighter remains on probation for an additional 6 months, for a total of 12 months.
The State requires a minimum of 468 hours of fire fighter training at a certified academy for fire fighter certification (International Fire Service Accreditation Congress: Fire fighter I and II, Hazardous Materials Awareness and Operations). Re-certification is required for EMTs/Paramedics every 4 years. Fire fighters are required by the State to receive 20 hours of fire fighter training annually. The Captain was certified as a Fire Fighter-Intermediate, Fire Service Instructor-Intermediate, EMT, and had 33 years of firefighting experience.
Pre-placement Medical Evaluations. The Fire Department requires a pre-placement medical evaluation for all new hires, regardless of age. Components of this evaluation include the following:
These evaluations are performed by a physician contracted with the City. Once this evaluation is complete, the contracted physician makes a determination regarding medical clearance for firefighting duties and forwards this decision to the City’s personnel director and the Fire Department.
Periodic Medical Evaluations. In 2007, the Fire Department began requiring annual medical evaluations. Components of this evaluation are the same as those of the pre-placement medical evaluation with three exceptions: the urine drug screen is not repeated, exercise stress tests are performed on all fire fighters over age 55, or exercise stress tests are performed if recommended by the Fire Department physician. The annual medical evaluation may be performed by the fire fighter’s primary care physician, provided the same components are included, and the results shared with the City-contracted physician. If follow-up is required, this can be provided by the City-contracted physician or the fire fighter’s personal physician. In all cases, the City-contracted physician makes the final decision regarding medical clearance for duty. Annual self-contained breathing apparatus (SCBA) medical clearance also began in 2007.
Health and Wellness Programs. In 2007, the Fire Department began a mandatory, non-punitive wellness/fitness program with 100% participation. The wellness/fitness program is overseen by a group of three peer fitness trainers as recommended by the International Association of Fire Fighters (IAFF)/International Association of Fire Chiefs (IAFC) wellness/fitness initiative [IAFF, IAFC 2000]. Exercise (strength and aerobic) equipment is located in some of the fire stations. Fire fighters are also given a local health club membership and have on-duty time to exercise. Health maintenance/wellness programs are available from the City.
In 2007, a mandatory annual fitness evaluation was also begun. Components of the fitness evaluation include:
Resting heart rate and blood pressure measurements are obtained prior to the aerobic capacity test. If the member’s resting heart rate exceeds 110 beats per minute, or the resting blood pressure exceeds 160/100 millimeters of mercury (mmHg), these vital signs are re-checked 5 minutes later. If the heart rate or blood pressure exceeds these values again, the member is referred for medical evaluation and rescheduled for another fitness evaluation in about 2 weeks. If a fire fighter fails to pass all components of the fitness evaluation, a Fire Department Peer Fitness Trainer prescribes an individual exercise program to strengthen areas of physical deficiency. These members are re-evaluated every month until the member passes the evaluation. Members who fail to pass on their targeted date, or who fail to make expected improvements in meeting their goals, are scheduled for a meeting with the Fire Department physician.
If an employee is injured at work, or is ill and off work for two 24-hour shifts or more, the fire fighter must be evaluated by his/her personal physician. The fire fighter then provides a medical release form to his/her shift commander. The shift commander then forwards the release to the City’s Human Resources Office, who makes the final determination regarding “return to work.”
The Captain’s sudden cardiac death was probably related to his atherosclerotic coronary artery disease (CAD), left ventricular hypertrophy, cardiomegaly, or any combination of these. In the United States, CAD (atherosclerosis) is the most common risk factor for cardiac arrest and sudden cardiac death [Meyerburg and Castellanos 2005]. Risk factors for its development include age over 45, male gender, family history of CAD, high blood pressure, high blood cholesterol, obesity, physical inactivity, and diabetes [American Heart Association (AHA) 1998; Jackson et al. 2001]. The Captain had five of these risk factors (age over 45, male gender, hypertension, high cholesterol, and mild obesity).
The narrowing of the coronary arteries by atherosclerotic plaques occurs over many years, typically decades [Libby 2005]. However, the growth of these plaques probably occurs in a nonlinear, often abrupt fashion [Shah 1997]. Heart attacks typically occur with the sudden development of complete blockage (occlusion) in one or more coronary arteries that have not developed a collateral blood supply [Fuster et al. 1992]. This sudden blockage is primarily due to blood clots (thromboses) forming on top of atherosclerotic plaques.
Establishing the occurrence of a heart attack requires any of the following: characteristic EKG changes, elevated cardiac enzymes, or coronary artery thrombus. In the Captain’s case, he never regained a heart rhythm on which an EKG could reveal characteristic changes, cardiac enzymes do not become positive for at least 4 hours post-heart attack and the Captain died within 1 hour after collapse, and no thrombus was found at autopsy [AHA 2006]. However, not all heart attacks have an associated coronary artery thrombus. On autopsy, the Captain had severe narrowing of his coronary arteries with atherosclerosis. Based on the clinical scenario, the Captain probably had an acute heart attack, which caused an arrhythmia and sudden cardiac death.
The Captain did not report any episodes of chest pain (angina) during physical activity (on or off-the-job), and he did not complain of angina during this episode, only that he did not feel well. The lack of chest pain does not rule out a heart attack because, in up to 20% of individuals, the first evidence of CAD may be myocardial infarction or sudden death [Libby 2005; Thaulow et al. 1993].
Cardiomegaly/Left Ventricular Hypertrophy. On autopsy, the Captain had an enlarged heart. This was probably due to his left ventricular hypertrophy resulting from his longstanding hypertension. Both cardiomegaly and left ventricular hypertrophy increase the risk of sudden cardiac death.
Occupational Medical Standards for Structural Fire Fighters. To reduce the risk of heart attacks and sudden cardiac arrest among fire fighters, the NFPA developed guidelines entitled “Standard on Comprehensive Occupational Medical Program for Fire Departments,”otherwise known as NFPA 1582 [NFPA 2007a]. NFPA recommends annual medical evaluations, including an EKG. Prior to the Captain’s death, annual medical evaluations were not required. Had an EKG been conducted as part of a Fire Department annual medical evaluation, perhaps the Captain’s left ventricular hypertrophy would have been detected by EKG. This may have led to further medical evaluation and treatment.
In addition to screening for risk factors for CAD, NFPA 1582 recommends conducting exercise stress tests on members over the age of 45 with two or more CAD risk factors (hypercholesterolemia, hypertension, smoking, diabetes mellitus, or family history of premature CAD) [NFPA 2007a]. These recommendations are similar to those of the American College of Cardiology (ACC)/American Heart Association (AHA) [Gibbons et al. 2002]. The Captain had two risk factors for CAD (hypercholesterolemia and hypertension), therefore an exercise stress test would have been indicated. Currently, the Fire Department only requires exercise stress tests for members age 55 and older, therefore, the Captain never had an exercise stress test. Had an exercise stress test been performed as part of a Fire Department annual medical evaluation, perhaps his underlying CAD would have been detected, leading to further medical evaluation and treatment.
The NIOSH investigator offers the following recommendations to address general safety and health issues. Had these recommendations been in place prior to 2007, perhaps the Captain’s sudden cardiac death could have been prevented.
Recommendation #1: Provide mandatory annual medical evaluations to fire fighters consistent with National Fire Protection Association (NFPA) 1582 to determine their medical ability to perform duties without presenting a significant risk to the safety and health of themselves or others.
Guidance regarding the content and frequency of these evaluations can be found in NFPA 1582 and in the IAFF/IAFC Fire Service Joint Labor Management Wellness/Fitness Initiative [NFPA 2007a; IAFF, IAFC 2000]. However, the Fire Department is not legally required to follow this standard or this initiative. Nonetheless, we recommend the City and Union work together to establish the content in order to be consistent with the above guidelines.
Recommendation #2: Incorporate exercise stress tests into the Fire Department’s medical evaluation program.
NFPA 1582, the IAFF/IAFC Fire Service Joint Labor Management Wellness/Fitness Initiative, and the ACC/AHA recommend an exercise stress test for male fire fighters over the age of 45 with two or more CAD risk factors [NFPA 2007a; Gibbons et al. 2002; IAFF, IAFC 2000]. The exercise stress test could be conducted by the fire fighter’s personal physician or the City contract physician. If the fire fighter’s personal physician conducts the test, the results must be communicated to the City physician, who should be responsible for decisions regarding medical clearance for firefighting duties.
Had a symptom-limiting exercise stress test been performed and the Captain’s underlying cardiac disease been identified, further evaluated, and treated, perhaps his sudden cardiac death could have been prevented at this time.
Recommendation 3: Provide fire fighters with medical clearance to wear self-contained breathing apparatus (SCBA) as part of the Fire Department’s medical evaluation program.
The Occupational Safety and Health Administration (OSHA)’s Revised Respiratory Protection Standard requires employers to provide medical evaluations and clearance for employees using respiratory protection [29 CFR1 1910.134]. These clearance evaluations are required for private industry employees and public employees in States operating OSHA-approved State plans. Texas does not operate an OSHA-approved State plan; therefore, public sector employers are not required to comply with OSHA standards. The Fire Department has implemented this recommendation with their 2007 annual medical evaluation.
Recommendation 4: Phase-in a comprehensive wellness and fitness program for fire fighters to reduce risk factors for cardiovascular disease and improve cardiovascular capacity.
We applaud the Fire Department for starting a mandatory wellness/fitness program consistent with NFPA 1583, Standard on Health-Related Fitness Programs for Fire Fighters, and the IAFF/IAFC Fire Service Joint Labor Management Wellness/Fitness Initiative [NFPA 2000; IAFF, IAFC 2000]. Worksite health promotion programs have been shown to be cost effective by increasing productivity, reducing absenteeism, reducing the number of work-related injuries, and reducing the number of work-related lost work days [Maniscalco et al. 1999; Stein et al. 2000; Aldana 2001; Stevens et al. 2002; IOM 2003, 2005]. Fire service health promotion programs have been shown to reduce coronary artery disease risk factors and improve fitness levels, with mandatory programs showing the most benefit [Blevins et al. 2006; Dempsey et al. 2002; Womack et al. 2005; Garfi et al. 1996; Harger et al. 1999]. One mandatory program was able to show a cost savings of $68,741 due to reduced absenteeism [Stein 2002]. A similar cost savings has been reported by the wellness program at the Phoenix Fire Department, where a 12-year commitment has resulted in a significant reduction in their disability pension costs [City Auditor1997].
Recommendation 5: Perform an annual physical performance (physical ability) evaluation to ensure fire fighters are capable of performing the essential job tasks of structural firefighting.
NFPA 1500, Standard on Fire Department Occupational Safety and Health Program [NFPA 2007b] requires Fire Department members who engage in emergency operations to be evaluated and certified annually by the Fire Department as meeting the physical performance requirements identified in paragraph 8–2.1 of the standard. The Fire Department implemented annual physical performance evaluations in 2007.
Recommendation #6: Eliminate or reduce thefrequency of periodic chest x-rays in asymptomatic fire fighters, unless clinically indicated.
According to NFPA 1582, “chest x-rays shall include an initial baseline and shall be repeated every 5 years or as medically indicated” [NFPA 2007a]. Chest x-rays are currently being conducted every other year during the FD’s annual medical evaluation. Conducting chest x-rays this frequently exposes members to unnecessary radiation and represents an unnecessary expense for the FD. In addition, these x-rays are not recommended by the OSHA Hazmat Standard, unless clinically indicated (e.g., respiratory symptoms) [CFR1 2002; NIOSH 1985].
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This investigation was conducted by and the report written by:
Tommy N. Baldwin, MS
Safety and Occupational Health Specialist
Mr. Baldwin, a National Association of Fire Investigators (NAFI) Certified Fire and Explosion Investigator, an International Fire Service Accreditation Congress (IFSAC) Certified Fire Officer I, a Kentucky Certified Fire Fighter and Emergency Medical Technician (EMT), and a former Fire Chief, is with the NIOSH Fire Fighter Fatality Investigation and Prevention Program, Cardiovascular Disease Component located in Cincinnati, Ohio.
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