Heart Attack! "Kicking In The Door" On The Leading Cause Of Fireground Deaths

One of a fire chief's saddest duties is attending the funeral of a firefighter. The tragedy of a line-of-duty death is internationally recognized and accepted throughout the fire service. The funerals are elaborate affairs with huge crowds made up of representatives from many places well beyond the dead firefighter's local area; this is as it should be, for these deaths represent the ultimate sacrifice of dedicated men and women, both career and volunteer.

Over the past 10 years, an average of 105 U.S. firefighters have died each year in the line of duty. Recent losses have decreased but it's time to "kick down the door" and attack the seat of the "blaze." Heart attack as a result of fireground stress is taking the largest toll on firefighter lives. This leading cause of death can be reduced or prevented through early identification of individual risk factors and modification of firefighter lifestyles.

Although the high-profile line-of-duty losses caused by wall collapse, exhausted self-contained breathing apparatus (SCBA), flashover and other risks that trained firefighters know they will face are spectacular, the fire service as a whole has been slow to acknowledge and attack the nature of most firefighter deaths. Just as we might be drawn away from the seat of a complex conflagration by other immediate considerations, so contemporary training focusing on the skills needed to suppress fire or render emergency medical care diverts us from examining and dealing directly with heart attack as the major reason for firefighter death.

The most recent reports of fireground deaths from the United States Fire Administration (USFA) and the Federal Emergency Management Agency (FEMA), for the years 1995 and 1996, tell us two things:

1. Almost half (48.9% for 1996 and 48% for 1995) of deaths occurring at incidents were the result of myocardial infarctions, better known as heart attacks.
2. Half of fireground deaths were caused by stress and/or exertion.

These percentages surpassed internal trauma (33% for 1996 and 25% for 1995), the second most prevalent reason for fireground fatalities. Burn deaths accounted for slightly less than 2% in the years studied.

Management and union organizations have been reluctant to hit the heart attack losses head-on in the same way an incident commander (IC) would be loath to order a master stream into an area known to be occupied by firefighters trying to reach the seat of a working fire. The IC has a duty to prevent a predictable screwup but if the scene suddenly explodes and interior personnel are trapped, there may be little choice but to use heavy-duty tactics not usually employed. Without doubt, the early results of the Wingspread Conferences indicate attention now being paid to this long-deferred issue (see "Wingspread IV: A Practical Look," March 1997).

It is time for all of us in the fire service to confront heart attack as a cause of firefighter death. The question of whose responsibility the problem is can be solved very quickly when we decide everyone owns it. Manage-ment, associations, unions, regulatory agencies, professional groups and, especially, individual firefighters all must take responsibility for quelling this one. Just as mutual aid protocols try to avoid asking, "Whose fire is this?" the fire service needs to say, "It is ours and we resolve to deal with it effectively."

It is tempting to think that heart attack deaths are simply a factor of an aging force. That is partially correct but 20 of the heart attacks reported in the 1996 data took place in the population whose ages ranged from 26-50 years. This represents 43.5% of all the heart attack deaths reported.

Those of us in the fire service know full well that we cannot expect a long retirement. We have spent a 30-year career attending funerals and all of us have memories of those we have worked alongside who are now gone. Why this stoic acceptance that our lives are just naturally going to be shorter than those of the general population? We react to the deaths caused by equipment failure or building construction deficiencies with an immediate "we won't let this happen again" approach while we ignore the most serious cause, fireground heart attack, because it is not so obvious.

The risk factors associated with heart disease are well-substantiated in the medical literature. Individual firefighters may be completely unaware of their own specific risks and how they can determine an individual health program. Even as this is being written, exciting developments in medical knowledge promise to make prediction of individual risk of heart disease more accurate. There is a growing consensus that adopting a healthy lifestyle and assuming personal responsibility for one's health will have a positive impact on wellbeing and quality of life.

We know that factors such as family history, weight, age, exercise, smoking, blood pressure, alcohol consumption, amount and type of cholesterol, and the presence or absence of depression can all interact to set the stage for a heart attack. To increase the span of healthy life, it is essential for a firefighter to know his or her own risk factors and demonstrate a willingness to adopt new health behaviors.

Emotional factors recently emerged in some heart research as more potent risk factors than once believed. This suggests both stress and its companion, depression, have a role in precipitating heart attack. Too frequently, the culture of the firefighter has made speaking about emotions and recognizing depression too hard to do, so a member slogs along alone, sometimes even where well-intentioned and high-quality employee-assistance programs have been in place for years.

Depression is often missed simply because the suffering member has lost self-awareness as part of the depressed state. Even when others are sympathetic and see depression signs in a co-worker, denial is commonly hard at work. To suffer from depression is still seen by many as weakness despite overwhelming evidence to the contrary.

Reducing Physical Stress

In view of the fact that 50% of fireground deaths are caused by stress and/or exertion, there have been significant advances in equipment design which have lead to reductions of physical stress. Few fire departments, however, have ongoing, effectively functioning emotional stress monitoring and management programs built-in to their organizations. While stress management is a complex issue, we cannot ignore its role in heart disease and believe it must be addressed on the basis of prevention as adequately as any other safety issue.

The fire service is changing and technology is improving every aspect of our job, including making it safer. Turnout gear, breathing apparatus, communications, hose - you name it, and it's being improved. Although occupational health and safety has commanded more attention in recent years, this attention has often been paid to resources firefighters use rather than to the firefighter as a resource. In what is still a very macho culture, it seems much easier to look at bunker gear specifications than to grapple with the emotional and physical stress that afflicts most personnel at a scene.

In addition to the changes in gear, what we do as firefighters has changed dramatically as well. Today, medical responses constitute the bulk of the workload for many departments. This ratio continues to increase in relation to demographic factors and with it, the risks associated with the job increase as well. How many firefighters had to worry about hepatitis B or AIDS a few years ago? Once again, these are the obvious risks. What about the exponential increase in emotional trauma resulting from what firefighters witness on a daily basis and the cumulative effects of this trauma? All of us still carry memories of dead and dying people from calls that are often many years old.

All of the technology in the world is not going to reduce these impacts. They are not physical and obvious and cannot be prevented by better equipment or improved operational techniques. It is predictable that, while the deaths from obvious causes will continue to decline in the coming years, the less obvious and more lethal causes such as heart attack will see an increase unless the fire service acts with a will and swiftness typically present only in a major disaster.

One of the authors of this article has participated in over 300 critical incident stress debriefing (CISD) sessions, enough to see the devastating impact a firefighter's death has on his or her peers as well as on family and friends. The distress many members feel at the loss of a colleague can be mitigated by CISD - but stress management after the fact was never intended to aid directly in the prevention of heart attack. A more comprehensive stress management program must be an integral part of the firefighter's life, not merely an add-on, one-day seminar.

It is also vital that stress management approaches look at the causes of stress attributable to the workplace and the firefighter's organizational culture. Too many stress management approaches have placed the onus for handling stress solely on the firefighter without allocating effective counseling and other support systems to make the firefighter's task achievable. This is inadequate and ignores many things now known about how to lessen the impact of environmental stressors.

In addition to stress management, continued awareness, development and implementation of age-appropriate physical fitness and nutrition programs must become the norm. Educational efforts in wellness must extend beyond the individual firefighter to his or her family or other personal support system.

A first step in stopping this major source of firefighter death is the use of a comprehensive, computerized health risk appraisal to determine the scope of the problem in given settings. From the data obtained in such an appraisal, members are given individually computed health reports outlining their major health risk factors, the likelihood of dying within the next 10 years and, most important, what the firefighter can do to reduce risks and the possibility of early death.

Planning groups of both management and union or associations may also receive data which does not identify any specific individual but allows for a look at the entire population surveyed in order to help establish interventions deemed most needed for a given group. This technique has had wide application in many North American settings and will become used more as the instruments are refined and their predictive ability increases.

Your heart is your life and your life affects your heart. When your job creates negative impacts such as stress or worry or depression on your life, your heart suffers and your life is shortened. We owe our firefighters just as much protection from these conditions as we give them from burns, smoke and building collapse. If this is to occur in the future fire service, emotional support and life style counselling will be just as important as new breathing apparatus or turnouts.

Heart disease can be prevented through early identification of health-risk factors and risk-reduction interventions which attack the seat of the blaze. The goal of health promotion acts to increase the firefighter's well-being and create conditions that maintain wellness, the firefighter's greatest protection in the line of duty.

Dr. William C. Brooks, a psychologist and former firefighter, is president of Psychwell Associates of Canada Ltd. He was instrumental in developing the Nova Scotia Firefighters' Critical Incident Stress Team from 1989 to 1995. He may be contacted by e-mail at: [email protected]. Joy Parsons-Nicota is a nurse educator with a master's degree in community health. She has been involved in many health promotion and educational pursuits in Canada and the United States, most recently in the Nurse Practitioner Program at the University of Ottawa (e-mail: [email protected]). Gary Richardson is chief of the Ottawa Fire Department. Previously, he served 23 years in the Winnipeg Fire Department in which he became deputy chief of Support Services. His master's degree thesis examined the role of EMS in the fire service. Active in the National Fire Protection Association, he is executive chair of the Ottawa-Carleton Regional Fire Chiefs Board (see www.fire.ottawa.on.ca).