Saving Our Own: Sudden Death with No Overtime

June 20, 2008
Today, firefighters dying in the line-of-duty almost always receive a comprehensive autopsy and for many, it is the closest thing they have had to a medical exam in years.Scalpel, please.

Today, firefighters dying in the line-of-duty almost always receive a comprehensive autopsy and for many, it is the closest thing they have had to a medical exam in years.

Scalpel, please.

The actual procedure has altered little over time. A "Y" incision is made beginning near the shoulders and converges at the sternum. This cut continues all the way to the pubic area and is deep enough to reach the rib cage and slices completely through the abdominal wall. The skin is peeled back to expose the ribs and the sternum which are then sawn away to reveal the vital organs. Using the most common method, known as Rokitansky, all of the body organs are removed at once. Each is then carefully weighed and examined, often microscopically to gather information about the presence of various diseases that may have contributed to the death of the individual.

Autopsy means, literally, see for one's self. Humans have been dissecting other humans for thousands of years but the "modern" autopsy can be traced to the nineteenth century when the practice became commonplace in European hospitals. This practice and the Napoleonic battlefields ensured that there would be plenty of bodies available for physicians to investigate the link between a diagnosis and the actual cause of death. Currently, autopsies are used to confirm clinical diagnosis, for research and for teaching purposes.

Today, firefighters dying in the line-of-duty almost always receive a comprehensive autopsy. In fact, for many, it is the closest thing they have had to a medical exam in years. It's the ultimate physical, only a little late. These autopsies reveal some stunning facts. Roughly 50 percent of the deaths that occur while firefighters are on duty are related to cardiovascular events. This compares with 22 percent for police and detectives, and 11 percent for EMS workers.

In 2005 the NFPA conducted a study of 1,006 firefighter fatalities spanning a 10-year period. The report found that 440 of the fatalities were due to sudden cardiac death. Researchers were able to obtain medical information in 308 of these cases. Almost half of the time, the dead firefighters had a prior, identified history of Cardiovascular Disease (CVD). Cardiovascular disease is an umbrella term which includes heart attacks, Coronary Heart Disease (CHD) and Coronary Artery Disease (CAD).

Died On-Duty
In 2003 researchers published a paper describing their findings on occupational and personal risk factors associated with firefighters dying of Coronary Heart Disease (CHD). They studied NIOSH Fire Fighter Fatality reports and other sources of information to explore the relationship between coronary fatalities and firefighting. Annually, in the US, firefighters spend less than two percent of their time on actual fire suppression duties yet firefighting accounted for 36 percent of CHD deaths. Fire suppression related training activities were also associated with an elevated risk of a fatal cardiac event.

The researchers also noted a time related correlation in their study. Despite the fact that most CHD deaths in the general population occur between 6 a.m. and noon, peak deaths for firefighters occur between noon and midnight, when the call load is the heaviest.

Their overall conclusion was well worth noting: Most on-duty CHD fatalities are work precipitated and occur in firefighters with underlying CHD.

The Role of Risk
Individual life risk can be defined as the quantifiable likelihood of loss under certain circumstances with all the circumstances being equal for all individuals. For firefighters, the risk of losing your life from CHD during fire suppression activity is not equal for all. Studies have consistently shown that the risk of dying of CHD during firefighting increases when the following factors or conditions are present:

  • Older than 45 years
  • Current smoker
  • Hypertension
  • Diabetes Mellitus
  • Cholesterol great than 200 mg/dl
  • Prior diagnosis of CHD or other evidence of arterial-occlusive disease.

Finally, at the time of the Kales study they found that 33 percent of firefighters were obese and that number had increased to 40 percent four years later. (Even firefighter recruits were overweight and had low-normal aerobic capacities.)

The good news is that many of the risk factors that can lead to a fatal cardiac event can be reduced or modified-if we are aware of them.

The Myth: It's the Fire Police
Many professionals are much taken with the myth that cardiac fatality statistics are artificially skewed upward by geriatric fire policemen in the Northeast and other places who are still responding when in their 70's or older. In fact, cardiac heart disease fatalities were more likely to be professionals. There were no significant differences in risk factors between professional and volunteer, and the majority of both groups had not undergone a fire department medical examination in the two years preceding their death.

Failing Grade
Most fire fighters killed in the line of duty die from a cardiac event caused by coronary heart disease (often previously diagnosed) despite the fact that professional standards and commonsense dictate that personnel should receive on-going and comprehensive medical screening and management.

Incredibly, 75 percent of the fatalities in the Kales study had not received a fire department medical examination within two years of the fatal incident. Kales also concluded that "on-duty CHD deaths are unlikely to occur in firefighters without traditional cardiovascular risk factors." A review of the last three years of NIOSH reports attributing cardiovascular disease as the cause of death also reveals that in a majority of cases, either no medical exam was conducted or the testing did not meet the requirements of the relevant NFPA standard.

Fire service leaders of every stripe are failing to take basic actions that would cut our death rate in half. Some national fire service leaders are suggesting that this is an issue for fire chiefs, alone, to confront and solve. Such an approach is doomed to failure. This situation is a complex occupational disaster which requires an equally complex solution that guarantees line firefighters will not lose by aggressively participating in programs designed to prevent or reduce CHD fatalities. In most departments, the current environment rewards ignorance, apathy and worse.

Leaders in both management and labor, pension trustees and elected officials all share responsibility for these needless deaths that occur like clockwork, on average, every eight days, year after year. The reasons for our inactivity are as likely to be social as they are scientific. Fear of job loss or being pushed out of a cherished avocation, though hardly rational when your life is at stake, can be more than reason enough to be (and stay) personally ignorant about our health. Fire department regulations, pension rules, rigid bureaucracies and a fundamental lack of creativity all help to craft an environment where firefighters gamble (and lose) where cardiac risk is concerned.

Into the Future
A majority of states and many municipalities now consider cardiovascular disease to be job-related. Firefighters typically qualify for some combination of medical, worker's compensation and pension coverage as a result of their condition. In those areas where such coverage is not afforded, we should build a similar safety net consisting of private medical insurance and job re-training to ensure that any member who suffers from coronary heart disease does not lose their employment as the result of a work-related medical condition.

Perhaps, at the end of the day, we need to change our concept of a career in the fire service. Given what we now know about the prevalence of heart disease and the role fire suppression activities play in fatal cardiac events, a fire service career might begin in the fire house and conclude in a productive support role where continued employment and a pension are ensured even for those who suffer from a serious cardiac condition.

The Kales study shows that we have the ability to eliminate 30 to 40 percent of on-duty fatalities if we so choose. Simple steps such as annual medical screening, working to reduce risk factors and alternate duty opportunities can dramatically reduce these fatalities.

It is now up to the fire service to make the changes that will save some 50 lives a year.

ERIC LAMAR lives and works in Washington, D.C. He has been involved in the fire service for 30 years. To read Eric's complete biography and view his archived articles, click here. You can reach Eric by e-mail at [email protected]..

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