July 26, 2006: A 43-year-old male firefighter suffers symptoms of heat strain while fighting a structure fire in Illinois. He cools down in rehab and his crew finds him dead at his residence hours later after he failed to answer his phone. The cause of death was listed as "clogged coronary artery" due to cardiovascular disease.
June 6, 2008: A 50-year-old volunteer firefighter reported to others he did not feel well after an afternoon of live-fire training on a hot and humid day. He rested in the air conditioning of an engine's cab for the remainder of the training session. He suffered a sudden cardiac death after the training was completed with the cause of death listed as cardiac arrhythmia due to a heart attack.
Aug. 9, 2008: A 47-year-old male volunteer firefighter reports feeling "a little tired" after completing live-fire training and is found unresponsive and pulseless minutes later; the cause of death was listed as atherosclerotic cardiovascular disease.
Feb. 27, 2009: A 45-year-old male career firefighter complains of not feeling well after returning from a call and retires to his bunk. He is found unresponsive and pulseless by his crew after he fails to turn out for the next call.
While reviewing fire service journals, the following situation seems to commonly replay: a firefighter complains of vague symptoms after responding to calls for service or vigorous training and is found dead hours later. While this is not a formal medical study, a quick review of National Institute for Occupational Safety and Health (NIOSH) firefighter fatality reports lists the cause of death is attributed to sudden cardiac death as a result of a heart attack.
According to the related NIOSH reports, the firefighters described in the first three accounts above had significant atherosclerotic cardiovascular disease, putting them all at risk for a heart attack and concluded that firefighting operations likely precipitated the heart attacks (the NIOSH report from the 2009 case has not yet been issued). This is consistent with medical studies that show firefighters with underlying cardiovascular disease are at the highest risk of suffering a sudden cardiac death due to the high stress of firefighting activities.
The textbook description of a heart attack is sudden, severe, crushing midsternal, or left-sided, chest pain radiating down the left arm or into the jaw. However, heart attacks can present many different symptoms and recent medical studies have suggested that the textbook description of a heart attack does not occur as frequently as once thought. When the blood supply to the heart is decreased, the body responds by activating the adrenergic, or "fight-or-flight," system. The body releases epinephrine as a compensation mechanism for the impaired cardiac function that can result in other symptoms. Other symptoms that can be associated with a heart attack include nausea, vomiting, general malaise (feeling ill or not feeling well), diaphoresis (cool, sweaty skin), anxiety or just the sense of feeling something is not right. The problem is that many of symptoms do not raise the flag for an impending heart attack in a relatively younger person, in the 30–50 age group, since most people associate the textbook symptoms with heart attacks.
Unfortunately, none of these symptoms are specific for a heart attack. Not every firefighter with the above complaints is having a heart attack. This is where all chiefs, officers, rehab personnel and firefighters must be more vigilant when firefighters have these complaints of not feeling well after calls or training.
Use your gut instinct; if firefighters tell you they don't feel well and they look as if they don't feel well, maybe these firefighters need to be evaluated in the emergency room. Chiefs and officers should insist that members be transported to the emergency department for evaluation. Rehab personnel should also be alert for firefighters complaining of vague symptoms while performing this function at incidents and carefully monitor these firefighters.
Denial is common during heart attacks, compound this with firefighters' aggressive attitudes and it may be very difficult to convince firefighters to go to the hospital for evaluation. Career firefighters can be forced to go for evaluation by their superior officers as it is work related. If a volunteer firefighter is being stubborn and insisting he or she wants to go home and sleep it off, perhaps a call to the member's spouse explaining why you are concerned could help bring that person to medical attention. A call to the emergency department explaining what you are concerned about may be helpful if the emergency room staff is not familiar with the cardiovascular risks of firefighters.
If a firefighter who is complaining of vague symptoms seeks medical care and is found to be having a heart attack, immediate therapy can be initiated, limiting the size of the clot in the clogged artery and opening the artery via angioplasty or thrombolytic agents, reducing the amount of damage to the heart muscle and increasing the chances of survival. However, if the firefighter is not suffering a heart attack, what is the loss? Maybe some inconvenience or lost time at work. Which option would you choose for you and your family, and your firefighters and their families?
While not all firefighters with vague complaints are suffering heart attacks, it appears to happen frequently enough that we should all be attuned for these vague complaints and transport these firefighters to the emergency room for evaluation. Do it for them and their families.
DR. RAYMOND BASRI, MD, FACP, is in the private practices of internal medicine and diagnostic cardiology in Middletown, NY. Dr. Basri is a Diplomate of the American Board of Internal Medicine and president of the Mid-Hudson Section. He received the 2008 Laureate Award of the American College of Physicians, of which he is a Fellow. Dr. Basri also is clinical assistant professor of medicine at New York Medical College, attending physician in the Department of Internal Medicine at Orange Regional Medical Center and on the consulting staff in cardiology at The Valley Hospital in Ridgewood, NJ. He is a member of the Excelsior Hook and Ladder Company in Middletown and a deputy fire coordinator for Orange County. Dr. Basri is the senior physician of the Disaster Medical Assistance Team (DMAT NY-4). He is a senior aviation medical examiner for the Federal Aviation Administration (FAA) and chief physician for Health & Safety Specialists in Medicine, which does onsite medical examinations for the fire service and consultant to FirePhysicals.com. ERIC BERGMAN, PA-C, is a physician assistant practicing internal medicine at Hartford Hospital in Hartford, CT. He earned a bachelor of science degree in allied health from the University of Connecticut and a master's degree from Albany Medical College. He is a member of the Killingworth, CT, Volunteer Fire Company; a past company officer and life member of the Avon, CT, Volunteer Fire Department; and a past member of the Shaker Road-Loudonville Fire Department in Colonie, NY.
