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Fire Fighter Suffers Heart Attack During Firefighting ...

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    Fire Fighter Suffers Heart Attack During Firefighting ... Fire Fighter Suffers Heart Attack During Firefighting ... Document Transcript

    • 2006 Death in the 17 Fire Fighter Fatality Investigation and Prevention Program line of duty… A summary of a NIOSH fire fighter fatality investigation February 2, 2007Fire Fighter Suffers Heart Attack During Firefighting Operationand Dies Forty Days Later – GeorgiaSUMMARYOn May 3, 2006, a 37-year-old male career as the cause of death. “AcinobacterFire Fighter (FF) conducted and participated in septicemia” and “excessive physical exertionan 8-hour live-fire training class prior to during firefighting activities” were listed asbeginning his shift at 1800 hours. In the early significant contributing conditions.morning hours of May 4th, he responded to aresidential fire. Wearing full turnout gear and It is unclear if any of the followingself-contained breathing apparatus (SCBA), recommendations could have prevented thisthe FF participated in fire suppression and FF’s death at this time. Nonetheless, NIOSHoverhaul activities. Afterward, he complained offers these recommendations to improve theof not feeling well and intermittent chest pain. FD’s overall health and safety program.On scene ambulance personnel evaluated theFF and despite normal vital signs, they • Ensure that fire fighters are cleared fortransported the FF to the local hospital’s duty by a physician knowledgeable aboutemergency department (ED). the physical demands of fire fighting, the personal protective equipment used byAn acute myocardial infarction (MI) was fire fighters, and the various componentsdiagnosed in the ED by electrocardiogram of NFPA 1582, Standard on(EKG) and cardiac enzyme tests. Despite Comprehensive Occupational Medicinetreatment with intravenous (IV) medications Program for Fire Departments.(clot dissolving drugs), the FF’s conditiondeteriorated and he was intubated and • Provide fire fighters with medicaltransferred to a tertiary care medical center. At evaluations and medical clearance tothat institution a cardiac catheterization wear SCBA.showed a thrombus (blood clot) in his The Fire Fighter Fatality Investigation and Preventioncoronary artery which was partially removed Program is conducted by the National Institute forby a specialized catheter (Rheolytic coronary Occupational Safety and Health (NIOSH). The purpose ofthrombectomy with AngioJet® Catheter). the program is to determine factors that cause or contributeAlthough the FF survived this initial event, his to fire fighter deaths suffered in the line of duty. Identification of causal and contributing factors enablecondition deteriorated in the intensive care unit researchers and safety specialists to develop strategies for(ICU) over the next 40 days. Due to his poor preventing future similar incidents. The program does notprognosis, on June 15, 2006, life support was seek to determine fault or place blame on fire departmentswithdrawn and he was pronounced dead at or individual fire fighters. To request additional copies of1945 hours. The death certificate and autopsy this report (specify the case number shown in the shield above), other fatality investigation reports, or further(completed by the County Medical Examiner) information, visit the Program Webs ite atlisted “hemodynamic failure” due to “healing http://www.cdc.gov/niosh/fire/and remote myocardial infarctions (MIs)” due to or call toll free“atherosclerotic coronary artery disease (CAD)” 1–800–35–NIOSH
    • Fatality Assessment and Control Evaluation 2006 Fire Fighter Fatality Investigation Investigation Report # F2006-17 and Prevention ProgramFire Fighter Suffers Heart Attack During Firefighting Operation and Dies Forty Days Later – Georgia• Develop a wellness/fitness program for • FD Operations Officer fire fighters to reduce risk factors for • FD Battalion Chief for Special cardiovascular disease (CVD) and Operations improve cardiovascular capacity. • International Association of Fire Fighters (IAFF) Local President• Perform an annual physical performance • Crew members (physical ability) evaluation to ensure fire • FF’s wife fighters are physically capable of performing the essential job tasks of NIOSH personnel reviewed the following structural firefighting. documents: • FD incident reports• Discontinue routine annual resting • FD training records electrocardiograms (EKGs) unless • FD standard operating guidelines medically indicated. • Ambulance reports • Hospital records• Discontinue annual screening chest • Death certificate x-rays unless medically indicated. • Autopsy report • Primary care provider (PCP) recordsINTRODUCTION & METHODS INVESTIGATIVE RESULTSOn May 4, 2006, a 37-year-old male FFsuffered a heart attack while performing fire On May 2nd and 3rd, 2006, the FF participatedsuppression and overhaul activities. Despite in fire fighter training at the County Fireadvanced cardiac life support (ACLS), he died Academy. On May 2, 2006, the FF conducted40 days later. NIOSH was notified of this interior search and rescue training from 0800fatality on June 14, 2006 by the United States hours until 1800 hours. The morning trainingFire Administration. NIOSH contacted the session included moving and raising 24-footaffected fire department (FD) on June 20, 2006 and 35-foot extension ladders, ascending/to obtain further information and to initiate the descending ladders, and victim (mannequin)investigation. On August 7, 2006, a Safety and removal. The afternoon training sessionOccupational Health Specialist from the included a) searching a smoke-filled structureNIOSH Fire Fighter Fatality Investigation and b) two live-burn evolutions (seeTeam traveled to Georgia to conduct an on-site Photograph 1). The search componentinvestigation of the incident. included ventilation practices, wall breach, window bailout, raise and lower systems fromDuring the investigation, NIOSH personnel ladders, and SCBA air consumption. The FFinterviewed the following people: participated in 15-20 searches, all while • Fire Chief wearing full turnout gear. The FF’s live-burn • FD Assistant Director evolutions were also conducted while wearing • FD Deputy ChiefPage 2
    • Fatality Assessment and Control Evaluation 2006 Fire Fighter Fatality Investigation Investigation Report # F2006-17 and Prevention ProgramFire Fighter Suffers Heart Attack During Firefighting Operation and Dies Forty Days Later – Georgia hungry. Otherwise, he had no complaints and ate dinner soon afterward. The FF retired to his quarters at 2100 hours. At 0030 hours on May 4, 2006, multiple FD apparatus including HR24 (a total of 17 personnel including the FF) were dispatched to a house fire with entrapment. Units arrived on scene at 0039 hours to find heavy smoke and flames. (See Table 1: Timeline). The occupants had escaped the flames prior to the FD’s arrival. The house was a tri-level, singlePhotograph 1. Fire Training Structure family dwelling, constructed of wood frame with brick and vinyl exterior (see Photograph 2).turnout gear including his SCBA. The It was located about 50 feet from the roadwaytemperature for the day rose to a high of 80º and six feet above grade. Door burglar barsFahrenheit (º F) with 41% relative humidity. were cut to gain access, thus delaying entry.On May 3, 2006, the same training occurred The fire was at the left (Side 2) and rear (Side 3)from 0800 hours until 1700 hours. The of the house. L20, E20, R20, and HR 24 weretemperature on the 2nd day rose to a high of assigned fire suppression duties.84º F and 43% relative humidity.After the training, the FF reported to Station24 for duty and was assigned to Heavy Rescue24 (HR24). The FD was dispatched to threecalls that evening. At 1814 hours, unitsincluding Truck 425 (T425) (including the FF)were dispatched to a house fire. T425 wascancelled en route at 1819 hours. At 1908hours, units including Truck 426 (T426)(including the FF) were dispatched to a rooffire. T426 returned to the station at 1920hours. The FF did not perform any firefighting duties at these two calls. Finally, at1926 hours, units including HR24 (includingthe FF) were dispatched to a motor vehicle Photograph 2. Fire Incidentaccident with entrapment. The FF assistedwith packaging and loading the patient into the The FF and his crew entered the structure andambulance. HR24 returned to the station at advanced a charged 1¾-inch hose line to the1943 hours. The FF spoke with his wife at second story to stop the forward extension of2000 hours and stated he was hot, tired, and the fire. Crew members breached the wall of aPage 3
    • Fatality Assessment and Control Evaluation 2006 Fire Fighter Fatality Investigation Investigation Report # F2006-17 and Prevention ProgramFire Fighter Suffers Heart Attack During Firefighting Operation and Dies Forty Days Later – Georgiabathroom to expose the fire, and the FF additional IV fluids and oxygen wereattacked the fire through the hole in the wall. administered. R10 arrived at the ED at 0159After passing the hose line to another crew hours.member, the FF and a crew member breachedwalls in two other rooms to check for fire Inside the ED, the FF reported being weak andspread. The FF’s SCBA low air alarm dizzy, but denied chest pain. A second IV wassounded, and he told his Captain that he was started, and the FF complained of worseningtired and needed a break. shortness of breath. He had an ashen skin color and was sweating profusely. CardiacThe FF left the structure and, once outside, auscultation revealed a heart murmur (gradedropped to his knees and removed his SCBA 2/6 systolic ejection murmur) and an S3facepiece. Crew members assisted the removal gallop, both signs consistent with heart failure.of his turnout coat. About 10 minutes later, the An EKG revealed changes consistent with anCaptain went outside and noticed that the FF acute anteroseptal MI (heart attack). Despitedid not look well. The Captain notified the treatment with oxygen, aspirin, Heparin, andSafety Officer (SO) that a fire fighter needed an intravenous clot dissolving drugimmediate medical attention. As the SO (thrombolytic agent), the FF’s conditionapproached the FF, he noticed the FF was deteriorated. His blood pressure went downrocking back and forth and sweating heavily. requiring IV medications (pressors), while his(Note: the weather was warm [65ºF with 85% heart rate and respiratory rate increased. Herelative humidity] and the fire conditions were was intubated (a breathing tube placed into thevery hot, therefore this amount of sweating trachea) just prior to transfer to a tertiary carewould not have been unusual). Regardless, the hospital. Tube placement was confirmed bySO notified B4 and Rescue 10 (R10) of the bilateral breath sounds, end tidal carbonsituation. dioxide, and chest x-ray. A carboxyhemoglobin (CoHb) level was notThe FF laid down onto the ground and obtained.commented that he was dehydrated and tired.After drinking some water, he reported some As the FF was being loaded into thechest pain. Crew members retrieved medical ambulance for transfer, his heart rhythmequipment. An intravenous (IV) line was changed to ventricular tachycardia (Vtach) (astarted, fluids were administered, and the FF life threatening heart rhythm), but IVbegan to feel better and his chest pain medications successfully returned his rhythmresolved. R10 personnel checked the FF (0120 to sinus tachycardia. The FF arrived at thehours) and his vital signs were as follows: tertiary care hospital where an echocardiogramblood pressure (BP) - 120/84 millimeters of revealed a left ventricular ejection fractionmercury (mmHg), pulse - 89 beats per minute (LVEF) of 15%-20% with essentially normal(bpm), and blood oxygen saturation - 99%. heart valves and ventricular walls. A cardiacDespite these normal vital signs and the FF not catheterization revealed a 90% occluded leftwanting to go to the hospital, B4 ordered him anterior descending (LAD) coronary arterytransported. At 0134 hours, R10 left the scene with a large thrombus (blood clot), with aen route to the hospital’s ED. En route, diffusely diseased left circumflex and rightPage 4
    • Fatality Assessment and Control Evaluation 2006 Fire Fighter Fatality Investigation Investigation Report # F2006-17 and Prevention ProgramFire Fighter Suffers Heart Attack During Firefighting Operation and Dies Forty Days Later – Georgiacoronary artery (RCA). The anterior wall of o Atherosclerotic lesions (50% -the left ventricle was severely hypokinetic 60% blockage) in most of the(diminished/slow moving) with an akinetic coronary arteries(not moving) apical wall. The LVEF was o Recent plaque hemorrhage andestimated to be 20%. Using a specialized rupture of the proximal portion ofcatheter (AngioJet®), the LAD thrombus was the LADpartially removed which improved the blood • No valve abnormalitiesflow down the LAD and past the thrombus. • No chamber dilation or hypertrophyAlthough the FF survived his acute MI, he On autopsy, the FF weighed 278 pounds andremained in critical condition in the ICU. Over was 72 inches tall, giving him a body massthe next 39 days, he suffered a number of index (BMI) of 37.69 kilograms per squarecomplications including a deep venous meter (kg/m2). A BMI >30.0 kg/m2 isthrombosis/pulmonary embolus, stroke considered obese.1(cerebrovascular accident [CVA]), AcuteRespiratory Distress Syndrome (ARDS) In 1988, at the age of 19, the FF wassecondary to multi-drug resistant diagnosed with lymphoma (Hodgkin’sAcinetobacter infection (sepsis), acute renal Disease). He underwent radiation therapy.failure, and pneumonia. On June 12th, an NIOSH could not verify reports stating that theintraaortic balloon pump was placed for FF also received chemotherapy. In 1989 thehemodynamic support. On June 13th, due to his FF had his spleen removed, reportedly due to apoor prognosis, the FF was removed from the physical trauma.life support machines and he died at 1945hours. In 2005, he was hospitalized for chest pain which occurred during firefighting activitiesMedical Findings. The death certificate and and was relieved by sublingual nitroglycerinautopsy (completed by the County Medical (medication for acute angina). A 12-lead EKGExaminer) listed “hemodynamic failure” due conducted by the paramedics in the fieldto “healing and remote MIs” due to “CAD” as revealed ST-segment depression in the anteriorthe cause of death. “Acinetobacter septicemia” and lateral leads suggestive of ischemia. Theand “excessive physical exertion during paramedics also reported a non-sustainedfirefighting activities” were listed as significant episode of Vtach and a 5-6 second episode ofcontributing conditions. Pertinent findings from asystole (no heart beat). In the ED, all histhe autopsy, performed on June 14, 2006, subsequent EKGs were normal and heincluded the following: displayed no arrhythmias. Three sets of sequential cardiac enzymes (Table 2) were • Atherosclerotic CAD performed which showed a rise and o Normal sized heart at 400 grams subsequent fall of the enzymes; a finding very o Old (healed) MI in the lateral suggestive of an MI. Two days later a cardiac portion of the left ventricle catheterization revealed a 99% blockage of a o Recent MI in the anteroseptal small branch (mid-lateral obtuse marginal) of portion of the left ventricle his left circumflex coronary artery. This arteryPage 5
    • Fatality Assessment and Control Evaluation 2006 Fire Fighter Fatality Investigation Investigation Report # F2006-17 and Prevention ProgramFire Fighter Suffers Heart Attack During Firefighting Operation and Dies Forty Days Later – Georgiawould have been responsible for blood flow to Employment and Training. The FD requiresthe inferior/lateral portion of the left ventricle. the following of all fire fighter applicants:He was also noted to have a reduced left • complete an applicationventricle function (an LVEF of 40%), global • possess a valid State driver’s licensehypokinesis, and minimal blockages (40%) of • possess a high school diploma orhis other coronary arteries. The consulting equivalentcardiologist was perplexed by the degree of • pass a written general knowledge testLV dysfunction in relation to his relatively • pass a background checkmild CAD. Therefore, the FF was discharged • pass a pre-employment physicalwith a diagnosis of primary cardiomyopathy examinationpossibly due to the following: viral, alcohol • pass a voice analysis test (lie detector)abuse, or radiation therapy. He was held out of • pass an oral interviewwork and then returned to restricted (driver or • pass a physical ability testteaching) duty after one week. The applicant is then offered employment. TheFollow-up by another cardiologist one month new hire is placed into a 16-week traininglater stated that the FF “has a dilated program to achieve the Fire Fighter I level.cardiomyopathy” and “he clearly has not had a The fire fighter is then placed into a 6-monthmyocardial infarction.” Three months later a Emergency Medical Technician (EMT)follow-up echocardiogram revealed normal school, if the fire fighter is not already anventricle function (LVEF 60%, normal sized EMT. Once the fire fighter becomes anchambers and physiologically normal valves). FF/EMT, the fire fighter is assigned to a fireThe FF was released to return to full duty with station and receives further FD-specificno restrictions. orientation and training. Fire fighters work 24 hours on-duty 0800 hours to 0800 hours, andAt the time of his death, the FF was taking two 48 hours off-duty. Every ninth shift is a “Kellycardiac prescription medications. According to Day” off.his wife and crew members, he did not expressany symptoms of cardiac-related problems The FF was certified as a Fire Fighter III,during the days or months prior to his death. Driver/Operator, EMT – Intermediate, Hazardous Materials Technician, Fire Service Instructor, Wildland Fire Fighter, Divemaster,DESCRIPTION OF THE FIRE Confined Space Rescue Technician, andDEPARTMENT certified in Technical Rope Rescue. He had 10 years of firefighting experience. He also servedAt the time of the NIOSH investigation, this as an adjunct instructor for the Georgia Statecareer FD consisted of 812 uniformed Fire Academy for 8 years and was an Assistantpersonnel, served a population of 678,000 in a Chief for his hometown’s volunteer FD.286 square-mile-area, and had 26 fire stations.Page 6
    • Fatality Assessment and Control Evaluation 2006 Fire Fighter Fatality Investigation Investigation Report # F2006-17 and Prevention ProgramFire Fighter Suffers Heart Attack During Firefighting Operation and Dies Forty Days Later – GeorgiaPre-placement/Periodic Medical Evaluation. Health/Wellness. An annual physical agilityA pre-placement medical evaluation is test is not required for members. There is arequired by this FD for all candidates. In voluntary wellness/fitness program, with eachaddition, an annual medical evaluation is shift having time set aside for physical fitnessrequired for all members. The medical exercise. Exercise equipment (strength andevaluations include the following components: aerobic) is available in the fire stations. Health and nutrition information is made available to • Complete medical history all firefighters. • Physical examination • Vital signs • Complete blood count • Complete metabolic panel (SMA 20) DISCUSSION • Vision screening CAD and the Pathophysiology of Sudden • Audiogram Cardiac Death (SCD). In the United States, • Urinalysis CAD (atherosclerosis) is the most common • Urine drug screen risk factor for cardiac arrest and SCD.2 Risk • Pulmonary function (spirometry) factors for its development include increasing • Resting EKG age, male gender, heredity, tobacco smoking, • Chest x-ray diabetes, high blood cholesterol, high BP, and physical inactivity/obesity.2 The FF had threeA County-contract physician performs the American Heart Association (AHA) riskmedical evaluations and forwards the factors for CAD: male gender, high bloodclearance-for-duty opinion to the County cholesterol, and obesity; he had CAD based onHuman Resources Office, who makes the final his cardiac catheterizations in 2005 and 2006decision regarding medical clearance for duty. and his autopsy report.Medical clearance for SCBA use is notrequired, but annual respirator fit tests are Narrowing of the coronary arteries byperformed. A return-to-duty medical clearance atherosclerotic plaques occurs over manyis required from the fire fighter’s PCP for years, typically decades.3 However, the growthduty-related injuries. If a non-duty-related of these plaques probably occurs in aillness prevents fire fighters from performing nonlinear, often abrupt fashion.4 Heart attackstheir duty, a return-to-duty clearance may be typically occur with the sudden developmentrequired by the fire fighter’s PCP. A job of complete blockage (occlusion) in one ordescription is included in the forms the PCP more coronary arteries that have not developedmust review and endorse. The clearance is a collateral blood supply.5 This suddenreviewed by the County Health Department blockage is primarily due to blood clotsphysician, who forwards the clearance form (thromboses) forming on the top of(without specific medical information) to the atherosclerotic plaques. The FF suffered afire fighter’s Battalion Chief and Risk heart attack in 2005 as determined by EKGManagement; the latter makes the final and blood tests of cardiac enzymes; hismedical clearance-for-duty decision. autopsy showed scarring (fibrosis) in thePage 7
    • Fatality Assessment and Control Evaluation 2006 Fire Fighter Fatality Investigation Investigation Report # F2006-17 and Prevention ProgramFire Fighter Suffers Heart Attack During Firefighting Operation and Dies Forty Days Later – Georgialateral portion of his left ventricle. The FF also In February 2005, the FF was diagnosed withhad a heart attack in May 2006 as determined dilated cardiomyopathy. This diagnosis wasby EKG, cardiac catheterization, and autopsy. made because the consulting cardiologist feltBlood clot (thrombus) formation in coronary the FF’s relatively minor CAD could not bearteries is initiated by disruption of responsible for his moderate LV dysfunction.atherosclerotic plaques. Certain characteristics However, a subsequent echocardiogram threeof the plaques (size, composition of the cap months later showed a normal-sized heart andand core, presence of a local inflammatory heart chambers with fully recovered LVprocess) predispose the plaque to disruption.5 function. Therefore, the diagnosis wasDisruption then occurs from biomechanical changed to probable stress cardiomyopathy.and hemodynamic forces, such as increased Stress cardiomyopathy is defined asBP, increased heart rate, increased temporarily weakened heart muscles.14-16 Itcatecholamines, and shear forces, which occur can easily be confused with a heart attack.during heavy exercise.6 However, instead of an acute blood clot (thrombus) triggering the event, suddenFirefighting is widely acknowledged to be one emotional stress may trigger stressof the most physically demanding and cardiomyopathy.14-16 The stress can precipitatehazardous of all civilian occupations.7 severe, reversible LV dysfunction in patientsFirefighting activities are strenuous and often without coronary disease. Exaggeratedrequire fire fighters to work at near maximal sympathetic stimulation is probably theheart rates for long periods. Even when energy underlying mechanism. It was originallycosts are moderate (as measured by oxygen described in Japan as Takotsubo Syndromeconsumption) and work is performed in a and, only recently, has it has been recognizedthermoneutral environment, heart rates may be in the Western world.14-16 Because the FF hadhigh (over 170 beats per minute), owing to the no known emotional stress prior to hisinsulative properties of the personal protective February 2005 episode, NIOSH investigatorsclothing.8 Epidemiologic studies have found consider his relatively small heart attack to bethat heavy physical exertion sometimes responsible for his reversible LV dysfunction.immediately precedes and triggers the onset ofacute heart attacks.9-12 Immediately preceding Occupational Medical Standards forthe onset of symptoms and in the 2 days Structural Fire Fighters. To reduce the risk ofbefore, the FF participated in multiple fire sudden cardiac arrest or other incapacitatingsuppression and overhaul activities while medical conditions among fire fighters, thewearing full turnout gear and SCBA. Most of National Fire Protection Association (NFPA)these activities occurred during periods of developed NFPA 1582, Standard onelevated temperatures and humidity. This is Comprehensive Occupational Medicalconsidered a very heavy level of physical Program for Fire Departments.17 NFPA 1582exertion.7,13 The physical stress of performing states that a history of MI compromises athese tasks, the elevated temperatures, and the member’s ability to safely perform suchpresence of underlying atherosclerotic CVD essential job tasks as firefighting, wearing ancontributed to the FF’s death. SCBA, climbing six or more flights of stairsPage 8
    • Fatality Assessment and Control Evaluation 2006 Fire Fighter Fatality Investigation Investigation Report # F2006-17 and Prevention ProgramFire Fighter Suffers Heart Attack During Firefighting Operation and Dies Forty Days Later – Georgiawhile wearing fire protective ensemble fire fighters can be found in NFPA 158217 andweighing at least 50 pounds, victim search and in the report of the International Association ofrescue, advancing water-filled hoselines Fire Fighters/International Association of Fire(weighing up to 130 pounds for a 50 foot Chiefs (IAFF/IAFC) wellness/fitness 18section of 2½-inch hoseline), prolonged initiative. Although the FD is not legallyperiods of extreme physical exertion, and required to follow any of these standards, theyfunctioning as an integral component of a provide effective guidelines for implementingteam.17 When evaluating a fire fighter after an a medical evaluation requirement.MI, NFPA 1582 recommends a radionuclidestress test to evaluate exercise tolerance and Applying NFPA 1582 involves economicthe presence of exercise-induced myocardial issues. These economic concerns go beyondischemia or ventricular arrhythmias.17 Even the costs of administering the medicalthough this FF’s LVEF had returned to normal program; they involve the personal andlevels after his MI in 2005, had an imaging economic costs of dealing with the medicalexercise stress test been performed, perhaps an evaluation results. NFPA 1500, Standard onabnormality might have been identified and he Fire Department Occupational Safety andwould have been restricted from full fire Health Program, Chapter 8-7.1 and 8-7.219fighting duty, thus preventing his sudden addresses these issues.cardiac death at this time. The physical evaluation could be conducted by the fire fighter’s primary care physician.RECOMMENDATIONS However, if the evaluation is performed by the fire fighter’s primary care physician, theIt is unclear if any of these recommendations results must be communicated to the Countycould have prevented this FF’s death at this physician, who makes the final determinationtime. Nonetheless, NIOSH offers these for clearance for duty.recommendations to improve the FD’s overallhealth and safety program. For fire fighters with a previous history of an MI, NFPA 1582 recommends restricted duty ifRecommendation #1: Ensure that fire any of the following are present:fighters are cleared for duty by a physicianknowledgeable about the physical demands of (1) Current angina pectoris even if relievedfire fighting, the personal protective by medicationequipment used by fire fighters, and thevarious components of NFPA 1582, (2) Persistent significant stenosis in anyStandard on Comprehensive Occupational coronary artery (> 70% lumen diameterMedicine Program for Fire Departments. narrowing) following treatmentGuidance regarding the content and frequency (3) Lower than normal LVEF as measuredof pre-placement and periodic medical by radionuclide scan, contrastevaluations and examinations for structural ventriculography, or echocardiographyPage 9
    • Fatality Assessment and Control Evaluation 2006 Fire Fighter Fatality Investigation Investigation Report # F2006-17 and Prevention ProgramFire Fighter Suffers Heart Attack During Firefighting Operation and Dies Forty Days Later – Georgia(4) Maximal exercise tolerance of < 42 Physical inactivity is the most prevalent milliliters of oxygen per minute per modifiable risk factor for CAD in the United kilogram or < 12 metabolic equivalents States. NFPA 1500 requires a wellness program (METS) that provides health promotion activities for preventing health problems and enhancing(5) Exercise-induced ischemia or ventricular overall well-being.19 NFPA 1583, Standard on arrhythmias observed by radionuclide Health-Related Fitness Programs for Fire stress test during an evaluation reaching Fighters, provides the minimum requirements at least a 12-METS workload for a health-related fitness program.21 In 1997, the IAFF/IAFC published a comprehensive Fire(6) History of MI, angina, or CAD with Service Joint Labor Management persistence of modifiable risk factor(s) Wellness/Fitness Initiative to improve fire fighter for acute coronary plaque rupture. quality of life and maintain physical and mental capabilities of fire fighters. Ten FDs across theRecommendation #2: Provide fire fighters United States joined this effort to poolwith medical evaluations and medical information about their physical fitnessclearance to wear SCBA. programs and create a practical fire service program. They produced a manual and a videoThe Occupational Safety and Health which details elements of such a program.18Administration (OSHA)’s Revised Respiratory Wellness programs have been shown to be costProtection Standard requires employers to effective, typically by reducing the number ofprovide medical evaluations and clearance for work-related injuries and lost work days.22-24employees using respiratory protection.20 Such Similar cost savings have been reported by theemployees include fire fighters who utilize wellness program at the Phoenix FD, where aSCBA in the performance of their duties. 12-year commitment has resulted in a significantThese clearance evaluations are required for reduction in their disability pension costs.25private industry employees and publicemployees in states operating OSHA-approved Recommendation #4: Perform an annualState plans. Georgia is not a State-plan state; physical performance (physical ability)therefore, public sector employers are not evaluation to ensure fire fighters arerequired to comply with OSHA standards. physically capable of performing the essentialHowever, the NIOSH investigator job tasks of structural firefighting.recommends voluntary compliance. Given theextensive annual medical evaluation being NFPA 1500 requires FD members who engageconducted, this medical clearance would not in emergency operations to be annuallyrepresent any additional cost to the FD. evaluated and certified by the FD as meeting the physical performance requirementsRecommendation #3: Develop a wellness/ identified in paragraph 8-2.1 of the standard.19fitness program for fire fighters to reduce The FD should conduct annual physical abilityrisk factors for CVD and improve tests to ensure the fire fighters are physicallycardiovascular capacity. capable of performing firefighting duties.Page 10
    • Fatality Assessment and Control Evaluation 2006 Fire Fighter Fatality Investigation Investigation Report # F2006-17 and Prevention ProgramFire Fighter Suffers Heart Attack During Firefighting Operation and Dies Forty Days Later – GeorgiaRecommendation #5: Discontinue routine REFERENCESannual resting EKGs unless medicallyindicated. 1. National Heart Lung Blood Institute [2003]. Obesity education initiative.According to NFPA 1582, “periodic resting [http://www.nhlbisupport.com/bmi/bmicaelectrocardiograms have not been shown to be lc.htm]. Date accessed: September 2006.useful, but can be reasonable as a member’sage increases.”17 These should be replaced by 2. AHA [1998]. AHA scientific position,stress EKGs for fire fighters at increased risk risk factors for coronary artery disease.for CAD defined as males over age 45 (or Dallas, TX: American Heart Association.females over age 55) with two or more CADrisk factors.17 The stress EKG is a much better 3. Libby P [2005]. The pathogenesis oftool for uncovering occult CAD or those at atherosclerosis. In: Kasper DL,risk for SCD. Therefore, only pre-placement Braunwald E, Fauci AS, Hauser SL,resting EKGs are recommended unless Longo DL, Jameson JL, eds. Harrison’smedically indicated by other information. The principles of internal medicine. 16th ed.current annual resting EKGs being conducted New York: McGraw-Hill, pp. 1425-1430.by the FD represent an unnecessary expensefor the FD. 4. Shah PK [1997]. Plaque disruption and coronary thrombosis: new insight intoRecommendation #6: Discontinue annual pathogenesis and prevention. Clinscreening chest x-rays unless medically Cardiol 20(11 Suppl2):II-38-44.indicated. 5. Fuster V, Badimon JJ, Badimon JHAccording to NFPA 1582, “chest x-rays shall [1992]. The pathogenesis of coronaryinclude an initial baseline and shall be artery disease and the acute coronaryrepeated every 5 years or as medically syndromes. N Engl J Med 326:242-250.indicated.”17 Chest x-rays are currently beingconducted every year during the FD’s annual 6. Kondo NI, Muller JE [1995]. Triggeringmedical evaluation. These x-rays expose of acute myocardial infarction. Jmembers to unnecessary radiation and Cardiovasc Risk 2:499-504.represent an unnecessary expense for the FD.In addition, these x-rays are not recommended 7. Gledhill N, Jamnik VK [1992].by the OSHA Hazmat Standard unless Characterization of the physical demandsclinically indicated (e.g., respiratory of firefighting. Can J Spt Sci 17(3):207- 26,27symptoms). 213.Page 11
    • Fatality Assessment and Control Evaluation 2006 Fire Fighter Fatality Investigation Investigation Report # F2006-17 and Prevention ProgramFire Fighter Suffers Heart Attack During Firefighting Operation and Dies Forty Days Later – Georgia 8. Smith DL, Petruzzello SJ, Kramer JM, et 15. Wittstein IS, Thiemann DR, Lima JAC, al. [1995]. Selected physiological and Baughman KL, Schulman SP, psychobiological responses to physical Gerstenblith G, Wu KC, Rade JJ, activity in different configurations of Bivalacqua TJ, Champion HC [2005]. firefighting gear. Ergonomics Neurohumoral features of myocardial 38(10):2065-2077. stunning due to sudden emotional stress. N Engl J Med 352(6):539-548. 9. Willich SN, Lewis M, Lowel H, et al. [1993]. Physical exertion as a trigger of 16. Pavin D, Le Breton H, Daubert C [1997]. acute myocardial infarction. N Engl J Human stress cardiomyopathy Med 329:1684-1690. mimicking acute myocardial syndrome. Heart 78:509-511.10. Mittleman MA, Maclure M, Tofler GH, et al. [1993]. Triggering of acute 17. NFPA [2007]. NFPA 1582: Standard on myocardial infarction by heavy physical comprehensive occupational medical exertion. N Engl J Med 329:1677-1683. program for fire departments. Quincy, MA: National Fire Protection11. Siscovick DS, Weiss NS, Fletcher RH, Association. Lasky T [1984]. The incidence of primary cardiac arrest during vigorous 18. IAFF, IAFC [2000]. The fire service exercise. N Engl J Med 311:874-877. joint labor management wellness/fitness initiative. Washington, DC: International12. Tofler GH, Muller JE, Stone PH, et al. Association of Fire Fighters, [1992]. Modifiers of timing and possible International Association of Fire Chiefs. triggers of acute myocardial infarction in the Thrombolysis in Myocardial 19. NFPA [2002]. NFPA 1500: Standard on Infarction Phase II (TIMI II) Study fire department occupational safety and Group. J Am Coll Cardiol 20:1049-1055. health program. Quincy, MA: National Fire Protection Association.13. American Industrial Hygiene Association Journal [1971]. Ergonomics 20. CFR. 29 CFR 1910.134, Respiratory guide to assessment of metabolic and protection. Code of Federal Regulations. cardiac costs of physical work. Am Ind Washington, DC: National Archives and Hyg Assoc J:560-564. Records Administration, Office of the Federal Register.14. Stress cardiomyopathy [2006]. [http://en.wikipedia.org/wiki/Stress_ 21. NFPA [2000]. NFPA 1583: Standard on cardiomyopathy]. Date accessed: health-related fitness programs for fire October 2006. fighters. Quincy, MA: National Fire Protection Association.Page 12
    • Fatality Assessment and Control Evaluation 2006 Fire Fighter Fatality Investigation Investigation Report # F2006-17 and Prevention ProgramFire Fighter Suffers Heart Attack During Firefighting Operation and Dies Forty Days Later – Georgia22. Maniscalco P, Lane R, Welke M, 27. NIOSH [1985]. Occupational safety and Mitchell J, Husting L [1999]. Decreased health guidance manual for hazardous rate of back injuries through a wellness waste site activities. Cincinnati, OH: program for offshore petroleum U.S. Department of Health and Human employees. J Occup Environ Med Services, Public Health Service, Centers 41:813-820. for Disease Control, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 85-115.23. Stein AD, Shakour SK, Zuidema RA [http://www.cdc.gov/niosh/pdfs/85-115- [2000]. Financial incentives, a.pdf]. Date accessed: September 2006. participation in employer sponsored health promotion, and changes in 28. American Heart Association [2006]. employee health and productivity: Blood tests for rapid detection of heart HealthPlus health quotient program. J attacks. Dallas, TX. Occup Environ Med 42:1148-1155. [http://www.americanheart.org/present24. Aldana SG [2001]. Financial impact of er.jhtml?identifier=4477]. Date health promotion programs: a accessed: July 2006. comprehensive review of the literature. Am J Health Promot 15:296-320. INVESTIGATOR INFORMATION25. Unpublished data [1997]. City Auditor, City of Phoenix, AZ. Disability retirement This investigation was conducted by and the program evaluation. January 28, 1997. report written by:26. CFR [2002]. 29 CFR 1910.120. Tommy N. Baldwin, MS Hazardous waste operations and Safety and Occupational Health Specialist emergency response. Subpart F – Medical Surveillance. Code of Federal Mr. Baldwin, a National Association of Fire Regulations. Investigators (NAFI) Certified Fire and [http://www.osha.gov/pls/oshaweb/owad Explosion Investigator, an International Fire isp.show_document?p_table=STANDA Service Accreditation Congress (IFSAC) RDS&p_id=975]. Date accessed: Certified Fire Officer I, a Kentucky Certified January 2006. 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.Page 13
    • Fatality Assessment and Control Evaluation 2006 Fire Fighter Fatality Investigation Investigation Report # F2006-17 and Prevention ProgramFire Fighter Suffers Heart Attack During Firefighting Operation and Dies Forty Days Later – Georgia Table 1: TIMELINE (FD Dispatch Center)0030 hours: Rescue 20 (R20), Squad 7 (S7), Engine 20 (E20), Engine 4 (E4), Engine 10 (E10), Ladder 20 (L20), Battalion 3 (B3), Battalion 4 (B4), Heavy Rescue 24 (HR24) respond to structure fire with heavy smoke and flames. Everyone is out of the house.0032 hours: E10, L20, E4, B3, B4, S7, R20, E20, and HR24 en route0039 hours: L20 and E10 on scene0040 hours: E4 on scene0041 hours: L20 assuming command0043 hours: B3 on scene0044 hours: R20 on scene0045 hours: Car 7, Engine 7 (E7), and Engine 6 (E6) en route. B3 requests two more Engines due to very heavy smoke0046 hours: E6 and HR 24 on scene0047 hours: E7 on scene0048 hours: Car 7 and S7 on scene0050 hours: B4 on scene0052 hours: Rescue 10 (R10) en route. B3 requests another Rescue.0055 hours: E6 on scene. E20, R20, L20, and B3 PAR0056 hours: E7 and E20 charge the 2½s0057 hours: E4 PAR0058 hours: E7, E10, S7, and B3 PAR0059 hours: B4 and E6 PAR. B3 PAR concluded0100 hours: R10 on scene. L20 is out of the building. Fire under control0104 hours: R10 assigned to rehab section0125 hours: R10 – fire fighter being transported to hospital for heat exhaustionPage 14
    • Fatality Assessment and Control Evaluation 2006 Fire Fighter Fatality Investigation Investigation Report # F2006-17 and Prevention ProgramFire Fighter Suffers Heart Attack During Firefighting Operation and Dies Forty Days Later – Georgia Table 2 Cardiac Enzymes 02/19/05 02/19/05 02/20/05 0135 0958 0645CK: 428 U/L 786 U/L 591 U/L (normal range is 22 - 269 U/L)CK-MB: 9.1 ng/mL 59.4 ng/mL 42.6 ng/mL (normal range is 0.1 - 5.0 ng/mL)Troponin I: 0.06 ng/mL 1.06 ng/mL 0.70 ng/mL (normal range is 0.01 - 0.03 ng/mL)Creatine kinase (CK) is the blood test most commonly used to confirm the existence of heart muscledamage.CK-MB, a small fraction of the CK enzyme, is often measured as well. CK-MB shows an increaseabove normal in a persons blood test about six hours after the start of a heart attack. It reaches itspeak level in about 18 hours and returns to normal in 24 to 36 hours. The peak level and the return tonormal can be delayed in a person whos had a large heart attack, especially if they dont get early andaggressive treatment.Tests can measure the level of other cardiac muscle proteins called troponins, specifically troponin T(cTnT) and troponin I (cTnI). These proteins control the interactions between actin and myosin,which contracts or squeezes the heart muscle. Troponins specific to heart muscle have been found,allowing the development of blood tests (assays) that can detect minor heart muscle injury("microinfarction") not detected by CK-MB. Normally the level of cTnT and cTnI in the blood isvery low. It increases substantially within several hours (on average four to six hours) of muscledamage. It peaks at 10 to 24 hours and can be detected for up to 10 to 14 days.28Page 15
    • U.S. Department of Health and Human Services Fatality Assessment and Control EvaluationCenters for Disease Control and PreventionNational Institute for Occupational Safety and Health4676 Columbia Parkway, MS C-13 Investigation Report # F2006-17Cincinnati, OH 45226-1998 Fire Fighter Suffers Heart Attack During Firefighting Operation and Dies Forty Days Later – Georgia___________________OFFICIAL BUSINESSPenalty for private use $300 Fire Fighter Fatality Investigation and Prevention ProgramDelivering on the Nation’s promise:Safety and health at work for all peopleThrough research and prevention 2006 Page 16