NIOSH Fire Fighter Fatality Investigation & Prevention Program - April, 2009


Fire Captain Suffers Fatal Heart Attack After Conducting Live Fire Training – Pennsylvania


On August 9, 2008, a 47-year-old male volunteer Captain led an attack team during live fire training. After finishing the 30-minute interior attack, the Captain rotated to an exterior, standby hose crew position. When the second interior crew finished its 30-minute fire attack exercise, all personnel reported to the rehabilitation (rehab) area. Medical personnel triaged all fire fighters. The Captain mentioned that he was “a little tired” but had no other complaints. Although the Captain’s pulse and respiratory rates were elevated, this was expected from anyone just completing a live fire exercise. After relaxing and drinking some water, the Captain related that he felt better. He left the rehab area, walked to his personal vehicle, and lay down on the grass. A short time later, two students walking nearby thought they heard the Captain snoring. They went over to investigate and heard a gurgling noise. They summoned the rehab emergency medical technician (EMT), instructors, and other students for help. A second ambulance was requested, cardiopulmonary resuscitation (CPR) was begun, and an automated external defibrillator (AED) delivered four shocks. The ambulance arrived, and paramedics began advanced life support. The Captain was transported to the hospital’s emergency department, where CPR and advanced life support treatment continued. Approximately 65 minutes after his collapse, despite CPR and advanced life support, the Captain died. 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. The results of the NIOSH investigation support this determination.

The NIOSH investigator offers the following recommendations to address general safety and health issues. Had these recommended measures been in place prior to the Captain’s collapse, his sudden cardiac death may have been prevented at this time.



On August 9, 2008, a 47-year-old male volunteer Fire Captain suffered a fatal heart attack after leading a live fire exercise. Despite CPR and advanced life support, the Captain died. NIOSH was notified of this fatality on August 11, 2008, by the U.S. Fire Administration. NIOSH contacted the affected Fire Department on August 18, 2008, to gather additional information, and on September 5, 2008, to initiate the investigation. On September 22, 2008, a safety and occupational health specialist from the NIOSH Fire Fighter Fatality Investigation Team traveled to Pennsylvania to conduct an on-site investigation of the incident.

During the investigation, NIOSH personnel interviewed the following people:

NIOSH personnel reviewed the following documents:



Incident. On August 9, 2008, the Captain (acting as ignition officer), along with a lead instructor, safety officer, rapid intervention team officer, and three assistant instructors lead a live fire exercise expected to last 8 hours. The class, held at the Community College Public Safety Training Center, had 13 students in attendance.

The class began at 0800 hours. Weather conditions included a temperature of 63 degrees Fahrenheit (°F) and 73% relative humidity [NOAA 2008]. The lead instructor gave the safety briefing and discussed the training elements: location of command, fire apparatus, rehab, radio communications, and personal protective equipment; burn building description; crew assignments; accountability; and emergency evacuation in accordance with NFPA 1403, Standard on Live Fire Training Evolutions [NFPA 2007a].

Vital signs were taken for each participant just prior to commencement of the exercises. The Captain’s blood pressure reading at 0830 hours was slightly elevated at 148/90 millimeters of mercury [mmHg]), but his pulse and respiratory rate were within normal limits. The Captain led the initial attack team of two students (Crew 1) into the Class A (wood incinerating) burn building (see Photograph 1 and Figure 1). Wearing full turnout gear and SCBA (on air), Crew 1 entered the burn building through Side A. During the live fire exercise, the ceiling temperature reached 1000 °F as measured by thermocouples (see Figure 2). The Captain advised the students about tactics on the first floor during the exercise. Crew 1 then advanced a charged 1¾-inch hoseline into the corner of the living room at the entrance to the garage, where the fire was located. They stopped briefly to observe the smoke conditions, then sprayed a stream high into the fire, then low into the fire. After initial knockdown, more fuel was added to the fire for the next burn, and Crew 1 retreated to the living room where the two Crew 1 students changed positions. Crew 1 then advanced the hoseline again, this time entering the garage area and knocking down the fire. Next, the crew hydraulically ventilated out the rear door for approximately 1 minute. Crew 1 then backed the hoseline out the front door. This exercise took approximately 30 minutes.

Photo 1

wood incinerating burn building

Figure 1

diagram of training house

Figure 2

thermocouples measurements of room temperatures

Crew 1, including the Captain, became the back-up crew during the second evolution. The Captain related how cool the temperature was that day compared to some previous classes with which he had been involved. The weather conditions at this time (0915 hours) included a temperature of 70°F and 57% relative humidity. After Crew 2 completed the second evolution (also about 30 minutes), an extended break was announced, and personnel reported to rehab, about 100 feet from the burn building. The emergency medical technician in rehab triaged all fire fighters. The Captain stated that he felt “a little tired.” The Captain’s vital signs were taken (at 1025 hours); his readings included a blood pressure of 132/86 (normal is <140/<90) mmHg, 22 respirations per minute (normal is 8-14 breaths per minute), and a pulse rate of 110 beats per minute (normal is 60-100). The EMT advised him to relax near the cool-misting system and drink some water, which he did for approximately 5–7 minutes. After a short time, the EMT asked the Captain how he was doing; the Captain replied that he felt better. The Captain then left the rehab area, walked approximately 150 feet to his parked car, and laid down on the grass.

At approximately 1040 hours, two students walking nearby heard a “snoring sound” coming from the Captain, as if he were sleeping. They went over to investigate and heard a “gurgling noise.” The two summoned the rehab EMT for help.

The EMT, several instructors, and students responded to the Captain. 911 was called, and a second ambulance was dispatched. The Captain was assessed and found to be unresponsive, not breathing, and without a pulse. CPR was begun, and the AED was retrieved. Four shocks were administered without a positive change in the Captain’s condition. The ambulance arrived at 1056 hours, and paramedics began advanced life support. A cardiac monitor was placed, revealing asystole. The Captain was successfully intubated on the second attempt, and oxygen administered; tube placement was confirmed by auscultation and visualization. An IV was begun, and cardiac resuscitation medications were administered; he was defibrillated four additional times. He was placed onto a stretcher and loaded into the ambulance, which departed the scene at 1120 hours en route to the hospital’s emergency department. No positive change occurred in the Captain’s condition during transport. The ambulance arrived at the hospital at 1140 hours. Inside the emergency department, advanced life support treatment continued until 1145 hours, when the Captain was pronounced dead by the attending physician.

Medical Findings. 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.



At the time of the NIOSH investigation, the volunteer Fire Department consisted of one fire station with 38 uniformed personnel. The department served 1,000 residents in a geographic area of 3.3 square miles.

In 2007, the Fire Department responded to 220 calls: 9 fires, 131 emergency medical calls, 34 motor vehicle accidents, 13 hazardous condition calls, and 35 other calls.

Membership and Training. The Fire Department votes on new fire fighter applicants, who must be at least 18 years of age and have a valid state driver’s license. New members must attend the 166-hour fire fighter essentials training course or have prior fire fighter experience. The State has no minimum requirement for fire fighter certification. The Captain was certified as a Fire Fighter II, Fire Officer, Instructor-Suppression Level, Emergency Medical Technician, Hazardous Materials Technician, Vehicle Rescue Technician, and Driver Operator; he had 22 years of fire fighting experience.

Preplacement and Periodic Medical Evaluation. Preplacement and periodic (annual) medical evaluations are not currently required by the Fire Department or the Training Center. An annual SCBA facepiece fit test is required by the Fire Department for interior structural fire fighters. However, SCBA medical clearance is not required. Members injured on duty must be evaluated by their primary care physician, who makes the final determination regarding return to duty.

Health and Wellness Programs. The Fire Department does not have a wellness/fitness program, but exercise (strength only) equipment is available in the fire station. Health maintenance programs are not available from the Town.



Cardiovascular Disease. In the United States, atherosclerotic CAD is the most common risk factor for cardiac arrest and sudden cardiac death [Meyerburg and Castellanos 2008]. 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 [AHA 2008]. The Captain had four of these risk factors (age over 45, male gender, high blood cholesterol, and obesity).

The narrowing of the coronary arteries by atherosclerotic plaques occurs over many years, typically decades [Libby 2008]. 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. At autopsy, the Captain had an acute thrombus in his left main coronary artery, confirming the diagnosis of a sudden heart attack.

Epidemiologic studies have found that heavy physical exertion sometimes immediately precedes and triggers the onset of acute heart attacks [Siscovick et al. 1984; Tofler et al. 1992; Mittleman et al. 1993; Willich et al. 1993]. Heart attacks in fire fighters have been associated with alarm response, fire suppression, and heavy exertion during training (including physical fitness training) [Kales et al. 2003; Kales et al. 2007; NIOSH 2007].The Captain had led a fire suppression exercise in a burn building while wearing full turnout gear and SCBA. While this activity could be considered light to moderate physical activity [AIHA 1971; Gledhill and Jamnik 1992], it occurred in a burn building with temperatures reaching 1000 °F. Given the Captain’s underlying CAD, his heart attack and subsequent sudden cardiac death was probably triggered by the physical stress of the fire suppression exercise, the high heat environment, and the use of full turnout gear and SCBA.

Cardiomegaly/Left Ventricular Hypertrophy. On autopsy, the Captain was found to have left ventricular hypertrophy (LVH) and an enlarged heart. This finding was not identified during his EKG and echocardiogram in 2006. Both LVH and cardiomegaly increase the risk for sudden cardiac death [Levy et al. 1990]. Hypertrophy of the heart’s left ventricle is a relatively common finding among individuals with long-standing high blood pressure, a heart valve problem, or chronic cardiac ischemia (reduced blood supply to the heart muscle) [Siegel 1997]. The Captain did not have high blood pressure or a heart valve problem; therefore, his LVH was probably due to chronic ischemia from his CAD.

Congenital Atrial Septal Defect. At autopsy, a congenital atrial septal defect was identified. Atrial septal defect is one of the most commonly recognized congenital cardiac anomalies. About 1 million Americans are affected [Therrien and Webb 2001]. However, because mild to moderate lesions are typically asymptomatic, the condition is rarely diagnosed [Friedman and Silverman 2001]. Patients with an atrial septal defect typically survive to old age despite being at increased risk for pulmonary hypertension, tricuspid incompetence, atrial fibrillation, paradoxic thromboembolism, or stroke [Rose 2001]. The diagnosis is typically made by echocardiogram.The Captain had an echocardiogram performed in 2006 which revealed only trace regurgitation.It is unclear why his atrial septal defect was not picked up during this evaluation.

According to the Forensic Pathologist, the Captain’s condition was thought to be of minor clinical significance because he did not have shortness of breath upon exertion and, on autopsy, he had normal cardiac chambers, no evidence of pulmonary hypertension, and no right ventricular hypertrophy.

Carbon Monoxide, Carboxyhemoglobin Levels, and Carbon Monoxide Poisoning. Carbon monoxide (CO) is a component of fire smoke. When inhaled, CO crosses the alveolar (lung) membrane and binds to hemoglobin, forming carboxyhemoglobin (COHb). The COHb reduces the availability of oxygen to other tissues and disrupts the intercellular use of oxygen which can lead to hypoxia (inadequate oxygen supply) [Alonso et al. 2003]. The brain and the heart are the organs most vulnerable to hypoxia. Symptoms/signs associated with CO poisoning include headache, dizziness, weakness, nausea, confusion, fast heart rate, and shortness of breath [Ernst and Zibrak 1998]. Upon entering rehab, the Captain had a fast heart rate and shortness of breath which were attributed to physical exertion during the live fire training, a reasonable attribution given the physical demands of the live fire evolution.

COHb levels in the blood are used to assess CO exposure and CO poisoning. COHb levels, however, do not correlate well with clinical findings and profound unconsciousness has been reported with levels less than 20% [Kindwall 1994; Piantadosi 2002]. CO levels in non-smokers are typically less than 3.0% [Ernst and Zibrak 1998]. At autopsy, the Captain’s COHb level was 9%. This level is higher than normal for a non-smoker, but not at a level considered dangerous [Piantadosi 2002]. Resuscitation efforts (intubation and administration of 100% oxygen for 55 minutes) would be expected to accelerate the elimination of COHb and lower COHb level [Ernst and Zibrak 1998; Alonso et al. 2003].  But the Captain never regained a heart beat, therefore these resuscitations measures are thought to have had minimal impact on his COHb level.

There is some evidence that prolonged exposure to low levels of CO may have adverse health effects, particularly cardiovascular. The adverse cardiovascular consequences reported at COHb levels of 2–5% include a decrease in exercise tolerance among healthy individuals and those with ischemic heart disease [Aronow and Cassidy 1975; Allred et al. 1989; Kleinman et al. 1989]. It has also been suggested that increased levels of CO might contribute to the development of coronary heart disease [Wald et al. 1973; Borland et al. 1983], possibly through effects on platelet and endothelial functioning [Thom and Ischiropoulos 1997], though this is speculative [Mennear 1993].

In summary, the Captain was exposed to carbon monoxide at some point during his live fire exercise and for an undetermined time; this probably caused the elevation of his COHb level. It is not clear what role, if any, this exposure had in triggering his heart attack and sudden cardiac death.

Occupational Medical Standards for Structural Fire Fighters. To reduce the risk of sudden cardiac arrest or other incapacitating medical conditions among fire fighters, the NFPA developed NFPA 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments [NFPA 2007b]. This voluntary industry standard provides the components of a preplacement and annual medical evaluation, and medical fitness for duty criteria. This standard recommends an exercise stress test performed “as clinically indicated by history or symptoms” and refers the reader to Appendix A [NFPA 2007b]. Items in the Appendix A are not standard requirements, but are provided for “informational purposes only.” Appendix A recommends that sub-maximal (85% of predicted heart rate) stress tests be used as a screening tool to evaluate a fire fighter’s aerobic capacity. Maximal (e.g., symptom limiting) stress tests with imaging should be use for fire fighters with:

The American College of Cardiology / American Heart Association (ACC/AHA) has also published exercise testing guidelines [Gibbons et al. 2002]. The ACC/AHA guideline states that the evidence to conduct stress tests in asymptomatic individuals with diabetes mellitus is “Class IIa” which is defined as “conflicting evidence and/or a divergence of opinion about the usefulness/efficacy but the weight of the evidence/opinion is in favor.” The ACC/AHA guideline says the evidence is “less well established” (Class IIb) for the following groups:

The U.S. Department of Transportation (DOT) has also provided guidance for those seeking medical certification for a commercial drivers license. An expert medical panel recommended exercise tolerance tests for asymptomatic “high risk” drivers [Blumenthal 2007]. The panel defines high risk drivers as those with any of the following:

The U.S. Preventive Services Task Force (USPSTF) does not recommend stress tests for asymptomatic individuals at low risk for coronary heart disease events.  For individuals at increased risk for coronary heart disease events, the USPSTF found “insufficient evident to recommend for or against routine screening with EKG, exercise tolerance test, or electron beam computerized tomography scanning….” Rather, they recommend the diagnosis and treatment of modifiable risk factors (hypertension, high cholesterol, smoking, and diabetes) [USPSTF 2004].  The USPSTF does note that “For people in certain occupations, such as pilots, and heavy equipment operators (for whom sudden incapacitation or sudden death may endanger the safety of others), consideration other than the health benefit to the individual patient may influence the decision to screen for coronary heart disease.”

According to NFPA, the ACC/AHA, and the U.S. DOT, the Captain should have had a stress test. The Captain’s underlying CAD could have been identified, and he probably would have been referred for further evaluation and treatment.

Physical Fitness Programs for Structural Fire Fighters. NFPA 1583, Standard on Health-Related Fitness Programs for Fire Department Members, establishes the minimum requirements for the development of a health-related fitness and exercise program and health promotion for fire department members involved in emergency operations [NFPA 2008a]. Members must be cleared annually for participation in a fitness assessment by the fire department physician and are required to participate in a periodic fitness assessment under the supervision of the fire department health and fitness coordinator [NFPA 2008a]. The fitness assessment includes 1) aerobic capacity, 2) body composition, 3) muscular strength, 4) muscular endurance, and 5) flexibility. The exercise and fitness program includes 1) education, 2) individualized participation, 3) warm-up and cool-down exercise guidelines, 4) aerobic exercise, 5) muscular strength and endurance, 6) flexibility exercise, 7) healthy back exercise, and 8) safety and injury prevention [NFPA 2008a].

NFPA 1500, Standard on Fire Department Occupational Safety and Health Program, requires the fire department to develop physical performance requirements for candidates and members who engage in emergency operations [NFPA 2007c]. Members who engage in emergency operations must be annually qualified (physical ability test) as meeting these physical performance standards [NFPA 2007c].

The National Volunteer Fire Council (NVFC) and the U.S. Fire Administration (USFA)’s Health and Wellness Project Health and Wellness Guide was developed to improve health and wellness within the volunteer fire service [USFA 2004]. This guide provides suggestions for successfully implementing a health and wellness program for volunteer fire departments.

Rehab Standards for Structural Fire Fighters. NFPA 1584, Standard on the Rehabilitation Process for Members During Emergency Operations and Training Exercises, establishes criteria for developing and implementing a rehab process for fire department members at incident scene operations and training operations [NFPA 2008b]. The Training Center should be commended for setting up and maintaining a rehab unit in compliance with NFPA 1584.

Live Fire Training Standards for Structural Fire Fighters. NFPA 1403, Standard on Live Fire Training Evolutions, contains requirements for training fire suppression personnel under live fire conditions [NFPA 2007a]. The Training Center should be commended for setting up and running a live fire training session consistent with NFPA 1403. A basic life support ambulance and emergency medical technician assistance was on site.



The NIOSH investigator offers the following recommendations to address general safety and health issues. Had these recommended measures been in place prior to the Captain’s collapse, his sudden cardiac death may have been prevented at this time.

Recommendation #1: Provide preplacement and annual medical evaluations to fire fighters consistent with National Fire Protection Association (NFPA) 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments, 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 International Association of Fire Fighters (IAFF)/International Association of Fire Chiefs (IAFC) Fire Service Joint Labor Management Wellness/Fitness Initiative [IAFF, IAFC 2000; NFPA 2007b]. However, the Fire Department and the Training Center are not legally required to follow this standard or this initiative. Applying this recommendation involves economic repercussions and may be particularly difficult for small volunteer fire departments to implement. NFPA 1500, Standard on Fire Department Occupational Safety and Health Program, paragraphs A.10.6.4 and A.11.1.1 and the National Volunteer Fire Council (NVFC) Health and Wellness Guide address these issues [USFA 2004; NFPA 2007c].

To overcome the financial obstacle of medical evaluations, the Fire Department could urge current members to get annual medical clearances from their private physicians. Another option is having the annual medical evaluations completed by paramedics and emergency medical technicians (EMTs) from the local EMS (vital signs, height, weight, visual acuity, and electrocardiogram [EKG]). This information could then be provided to a community physician (perhaps volunteering his or her time), who could review the data and provide medical clearance (or further evaluation, if needed). The more extensive portions of the medical evaluations could be performed by a private physician at the fire fighter’s expense (personal or through insurance), provided by a physician volunteer, or paid for by the Fire Department, City, or State. Sharing the financial responsibility for these evaluations between fire fighters, the Fire Department, the City, the State, and physician volunteers may reduce the negative financial impact on recruiting and retaining needed fire fighters.

Recommendation #2: Ensure that fire fighters are cleared for return to duty by a physician knowledgeable about the physical demands of fire fighting, the personal protective equipment used by fire fighters, and the various components of NFPA 1582.

Guidance regarding medical evaluations and examinations for structural fire fighters can be found in NFPA 1582 [NFPA 2007b] and in the IAFF/IAFC Fire Service Joint Labor Management Wellness/Fitness Initiative [IAFF, IAFC 2000]. According to these guidelines, the Fire Department should have an officially designated physician who is responsible for guiding, directing, and advising the members with regard to their health, fitness, and suitability for duty as required by NFPA 1500, Standard on Fire Department Occupational Safety and Health Program [NFPA 2007c]. The physician should review job descriptions and essential job tasks required for all Fire Department positions and ranks in order to understand the physiological and psychological demands of fire fighters and the environmental conditions under which they must perform, as well as the personal protective equipment they must wear during various types of emergency operations.

Recommendation #3: Phase in a comprehensive wellness and fitness program for fire fighters to reduce risk factors for cardiovascular disease and improve cardiovascular capacity.

Guidance for fire department wellness/fitness programs is found in NFPA 1583, Standard on Health-Related Fitness Programs for Fire Fighters, and the IAFF/IAFC Fire Service Joint Labor Management Wellness/Fitness Initiative [IAFF, IAFC 2000; NFPA 2008a]. Worksite health promotion programs have been shown to be cost effective by increasing productivity, reducing absenteeism, and reducing the number of work-related injuries and lost work days [Stein et al. 2000; Aldana 2001]. Fire service health promotion programs have been shown to reduce CAD risk factors and improve fitness levels, with mandatory programs showing the most benefit [Dempsey et al. 2002; Womack et al. 2005; Blevins et al. 2006]. A recent study conducted by the Oregon Health and Science University reported a savings of more than $1 million for each of four large fire departments implementing the IAFF/IAFC wellness/fitness program compared to four large fire departments not implementing a program. These savings were primarily due to a reduction of occupational injury/illness claims with additional savings expected from reduced future nonoccupational healthcare costs [Kuehl 2007].

Recommendation #4: Provide fire fighters with medical clearance to wear SCBA as part of the Fire Department’s medical evaluation program.

The Occupational Safety and Health Administration (OSHA) 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. Pennsylvania does not operate an OSHA-approved State plan; therefore, public sector employers (including volunteer/paid fire departments) are not required to comply with OSHA standards. Nonetheless, NIOSH investigators recommend voluntary compliance with this OSHA standard.

Recommendation #5: Use a secondary (technological) test to confirm appropriate placement of the endotracheal tube.

To reduce the risk of improper intubation, the American Heart Association and the International Liaison Committee on Resuscitation published recommendations in the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care [AHA 2000]. These guidelines recommend confirming tube placement by primary and secondary methods. Primary confirmation is the five-point auscultation: left and right anterior chest, left and right midaxillary, and over the stomach. Secondary confirmation requires a technology test, either an end-tidal carbon dioxide detector or an esophageal detector device. In this incident, the Captain had bilateral breath sounds confirmed by auscultation and chest rise; however, secondary confirmation was not performed. This recommendation does not imply that the endotracheal tube was misplaced or that it contributed to the Captain’s death. We raise this issue only to ensure that future advanced life support resuscitation efforts follow AHA guidelines.

Recommendation #6: Recheck vital signs of fire fighters prior to leaving rehab.

While not specifically required by NFPA 1584, fire fighter’s vital signs should be rechecked prior to leaving rehab to ensure there is no medical condition to preclude the fire fighter from participating in further activities. Upon exiting rehab, the fire fighter should be directed to the rest and refreshment unit or to the medical evaluation/treatment unit [USFA 2008].

1Code of Federal Regulations. See CFR in references.



AHA [2000]. Advanced cardiovascular life support: section 3: adjuncts for oxygenation, ventilation, and airway control. Circ 102(8)(Suppl):I-95 – I-104.

AHA [2008]. AHA scientific position, risk factors for coronary artery disease. Dallas, TX: American Heart Association. []. Date accessed: August 2008. (Link Updated 1/17/2013)

AIHA [1971]. Ergonomics guide to assessment of metabolic and cardiac costs of physical work. Am Ind Hyg Assoc J 32(8):560–564.

Aldana SG [2001]. Financial impact of health promotion programs: a comprehensive review of the literature. Am J Health Promot 15(5):296–320.

Allred EN, Bleecker ER, Chaitman BR, Dahms TE, Gottlieb SO, Hackney JD, Pagano M, Selvester RH, Walden SM, Warren J [1989]. Short-term effects of carbon monoxide exposure on the exercise performance of subjects with coronary artery disease.  N Engl J Med 321(21):1426-1432.

Alonso JR, Cardellach F, Lopez S, Casademont J, Miro O [2003] Carbon monoxide specifically inhibits cytochrome c oxidase of human mitochondrial respiratory chain. Pharmacol Toxicol 93(3):142-146.

Aronow WS, Cassidy J [1975]. Effect of carbon monoxide on maximal treadmill exercise. A study in normal persons.  Ann Intern Med 83(4):496-499.

Blevins JS, Bounds R, Armstrong E, Coast JR [2006]. Health and fitness programming for fire fighters: does it produce results? Med Sci Sports Exerc 38(5):S454.

Blumenthal RS, Epstein AE, Kerber RE [2007].  Expert panel recommendations. Cardiovascular disease and commercial motor vehicle driver safety.  [].  Date accessed: July 30, 2008. 

Borland C, Chamberlain A, Higenbottam T, Shipley M, Rose G [1983]. Carbon monoxide yield of cigarettes and its relation to cardiorespiratory disease. Br Med J (Clin Res Ed) 287(6405):1583-1586.

CDC (Centers for Disease Control and Prevention) [2008]. BMI – Body Mass Index. []. Date accessed: August 2008.

CFR. Code of Federal Regulations. Washington, DC: U.S. Government Printing Office, Office of the Federal Register.

Dempsey WL, Stevens SR, Snell CR [2002]. Changes in physical performance and medical measures following a mandatory firefighter wellness program. Med Sci Sports Exerc 34(5):S258.

Ernst A, Zibrak JD [1998]. Carbon monoxide poisoning. N Engl J Med 339(22):1603-1608.

Friedman WF, Silverman N [2001]. Congenital heart disease in infancy and childhood. In: Heart disease. Braunwald E, Zipes DP, Libby P, eds. 6th ed. Philadelphia, PA: W.B. Saunders, pp. 1524-1526.

Fuster V, Badimon L, Badimon JJ, Chesebro JH [1992]. The pathogenesis of coronary artery disease and the acute coronary syndromes. N Engl J Med 326(4):242–250.

Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher VF, Mark DB,  McCallister BD, Mooss AN, O'Reilly MG, Winters WL, Jr. [2002].  ACC/AHA 2002 guideline update for exercise testing: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.  Circulation 106(14):1883-1892.

Gledhill N, Jamnik VK [1992]. Characterization of the physical demands of firefighting. Can J Spt Sci 17(3):207–213.

IAFF, IAFC [2000]. The fire service joint labor management wellness/fitness initiative. 2nd ed. Washington, DC: International Association of Fire Fighters, International Association of Fire Chiefs.

Kales SN, Soteriades ES, Christoudias SG, Christiani DC [2003]. Firefighters and on-duty deaths from coronary heart disease: a case control study. Environ health: a global access science source. 2:14. []. Date accessed: September 10, 2008.

Kales SN, Soteriades ES, Christophi CA, Christiani DC [2007]. Emergency duties and deaths from heart disease among fire fighters in the United States. N Engl J Med 356(12):1207–1215.

Kindwall EP [1994]. Carbon Monoxide. In Zenz C, Dickerson OB, Horvath EP (Eds). Occupational Medicine, 3rd Edition. Mosby-Year Book, Inc. St Louis, MO.

Kleinman MT, Davidson DM, Vandagriff RB, Caiozzo VJ, Whittenberger JL [1989]. Effects of short-term exposure to carbon monoxide in subjects with coronary artery disease.  Arch Environ Health 44(6):361-369.

Kuehl K [2007]. Economic Impact of the Wellness Fitness Initiative. Presentation at the 2007 John P. Redmond Symposium in Chicago, IL on October 23, 2007.

Levy D, Garrison RJ, Savage DD, Kannel WB, Castelli WP [1990]. Prognostic implications of echocardiographically determined left ventricular mass in the Framingham Heart Study. N Engl J Med 323(24):1706–1707.

Libby P [2008]. The pathogenesis, prevention, and treatment of atherosclerosis. In: Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J, eds. Harrison’s principles of internal medicine. 17th ed. New York: McGraw-Hill, pp. 1501–1509.

Meyerburg RJ, Castellanos A [2008]. Cardiovascular collapse, cardiac arrest, and sudden cardiac death. In: Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J, eds. Harrison’s principles of internal medicine. 17th ed. New York: McGraw-Hill, pp. 1707–1713.

Mennear JH [1993]. Carbon monoxide and cardiovascular disease: an analysis of the weight of evidence. Regul Toxicol Pharmacol 17(1):77-84.

Mittleman MA, Maclure M, Tofler GH, Sherwood JB, Goldberg RJ, Muller JE [1993]. Triggering of acute myocardial infarction by heavy physical exertion. N Engl J Med 329(23):1677–1683.

NFPA [2007a]. Standard on live fire training evolutions. Quincy, MA: National Fire Protection Association. NFPA 1403.

NFPA [2007b]. Standard on comprehensive occupational medical program for fire departments. Quincy, MA: National Fire Protection Association. NFPA 1582.

NFPA [2007c]. Standard on fire department occupational safety and health program. Quincy, MA: National Fire Protection Association. NFPA 1500.

NFPA [2008a]. Standard on health-related fitness programs for fire fighters. Quincy, MA: National Fire Protection Association. NFPA 1583.

NFPA [2008b]. Standard on the rehabilitation process for members during emergency operations and training exercises. Quincy, MA: National Fire Protection Association. NFPA 1584.

NIOSH [2007]. NIOSH alert: preventing fire fighter fatalities due to heart attacks and other sudden cardiovascular events. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2007-133.

NOAA [2008]. Quality controlled local climatological data. National Oceanic and Atmospheric Administration. []. Date accessed: August 2008.

Piantadosi CA [2002]. Carbon monoxide poisoning.  N Engl J Med 347(14):1054-1055.

Rose [2001]. Diseases of the pulmonary circulation. In: Silver MD, Gotlieb AI, Schoen FJ, eds. Cardiovascular pathology. 3rd ed. Philadelphia, PA: Churchill Livingstone, p. 168.

Seidman C, Sampson B [2001]. Genetic causes of diseases affecting the heart and great vessels. In: Silver MD, Gotlieb AI, Schoen FJ, eds. Cardiovascular pathology. 3rd ed. Philadelphia, PA: Churchill Livingstone, p. 769.

Shah PK [1997]. Plaque disruption and coronary thrombosis: new insight into pathogenesis and prevention. Clin Cardiol 20 (11 Suppl2):II-38–44.

Siegel RJ [1997]. Myocardial hypertrophy. In: Bloom S, ed. Diagnostic criteria for cardiovascular pathology acquired diseases. Philadelphia, PA: Lippencott-Raven, pp. 55–57.

Siscovick DS, Weiss NS, Fletcher RH, Lasky T [1984]. The incidence of primary cardiac arrest during vigorous exercise. N Engl J Med 311(14):874–877.

Stein AD, Shakour SK, Zuidema RA [2000]. Financial incentives, participation in employer sponsored health promotion, and changes in employee health and productivity: HealthPlus health quotient program. J Occup Environ Med 42(12):1148–1155.

Therrien J, Webb GD [2001]. Congenital heart disease in adults. In: Heart disease. Braunwald E, Zipes DP, Libby P, eds. 6th ed. Philadelphia, PA: W.B. Saunders, pp. 1592-1593.

Thom SR, Ischiropoulos H [1997]. Mechanism of oxidative stress from low levels of carbon monoxide. In: Research Report No 80. Philadelphia, PA: Health Effects Institute.

Tofler GH, Muller JE, Stone PH, Forman S, Solomon RE, Knatterud GL, Braunwald E [1992]. Modifiers of timing and possible triggers of acute myocardial infarction in the Thrombolysis in Myocardial Infarction Phase II (TIMI II) Study Group. J Am Coll Cardiol 20(5):1049–1055.

USFA [2004]. Health and wellness guide. Emmitsburg, MD: Federal Emergency Management Agency; United States Fire Administration. Publication No. FA-267.

USFA [2008]. Emergency incident rehabilitation. Emmitsburg, MD: Federal Emergency Management Agency; United States Fire Administration.

USPSTF [2004]. U.S. Prevention Services Task Force.  Screening for coronary heart diease: Recommendation Statement.  Ann Intern Med 140:569-572.

Wald N, Howard S, Smith PG, Kjeldsen K [1973]. Association between atherosclerotic diseases and carboxyhaemoglobin levels in tobacco smokers.  Br Med J 1(5856):761-765.

Willich SN, Lewis M, Lowel H, Arntz HR, Schubert F, Schroder R [1993]. Physical exertion as a trigger of acute myocardial infarction. N Engl J Med 329(23):1684–1690.

Womack JW, Humbarger CD, Green JS, Crouse SF [2005]. Coronary artery disease risk factors in firefighters: effectiveness of a one-year voluntary health and wellness program. Med Sci Sports Exerc 37(5):S385.



This incident was investigated by the NIOSH Fire Fighter Fatality Investigation and Prevention Program, Cardiovascular Disease Component located in Cincinnati, Ohio. Mr. Tommy Baldwin (M.S.) led the investigation and co-authored the report. Mr. Baldwin is a Safety and Occupational Health Specialist, a National Association of Fire Investigators (NAFI) Certified Fire and Explosion Investigator, an International Fire Service Accreditation Congress (IFSAC) Certified Fire Officer I, and a former Fire Chief and Emergency Medical Technician. Dr. Thomas Hales (M.D., M.P.H.) provided medical consultation and co-authored the report. Dr. Hales is a member of the NFPA Technical Committee on Occupational Safety and Heath, and Vice-Chair of the Public Safety Medicine Section of the American College of Occupational and Environmental Medicine (ACOEM).

Appendix A

Autopsy Findings



Armstrong WF, Feigenbaum H [2001]. Echocardiography. In: Braunwald E, Zipes DP, Libby P, eds. Heart disease: a text of cardiovascular medicine. 6th ed. Vol. 1. Philadelphia, PA: W.B. Saunders Company, p. 167.

Colucci WS, Braunwald E [1997]. Pathophysiology of heart failure. In: Braunwald, ed. Heart disease. 5th ed. Philadelphia, PA: W.B. Saunders Company, p. 401.

Silver MM and Silver MD [2001]. Examination of the heart and of cardiovascular specimens in surgical pathology. In: Silver MD, Gotleib AI, Schoen FJ, eds. Cardiovascular pathology. 3rd ed. Philadelphia, PA: Churchill Livingstone, pp. 8-9.

Winek CL [1976]. Tabulation of therapeutic, toxic, and lethal concentrations of drugs and chemicals in blood. Clin Chem 22 (6):832-836.


The National Institute for Occupational Safety and Health (NIOSH), an institute within the Centers for Disease Control and Prevention (CDC), is the federal agency responsible for conducting research and making recommendations for the prevention of work-related injury and illness. In fiscal year 1998, the Congress appropriated funds to NIOSH to conduct a fire fighter initiative. NIOSH initiated the Fire Fighter Fatality Investigation and Prevention Program to examine deaths of fire fighters in the line of duty so that fire departments, fire fighters, fire service organizations, safety experts and researchers could learn from these incidents. The primary goal of these investigations is for NIOSH to make recommendations to prevent similar occurrences. These NIOSH investigations are intended to reduce or prevent future fire fighter deaths and are completely separate from the rulemaking, enforcement and inspection activities of any other federal or state agency. Under its program, NIOSH investigators interview persons with knowledge of the incident and review available records to develop a description of the conditions and circumstances leading to the deaths in order to provide a context for the agency’s recommendations. The NIOSH summary of these conditions and circumstances in its reports is not intended as a legal statement of facts. This summary, as well as the conclusions and recommendations made by NIOSH, should not be used for the purpose of litigation or the adjudication of any claim. For further information, visit the program website at or call toll free 1-800-CDC-INFO (1-800-232-4636).


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