Firefighter`s Cardiac Death Prompts NIOSH Investigation

Moments after packaging and dispatching his patient to the hospital, the first-year firefighter collapsed. His FD and EMS colleagues frantically treated him on scene for 32 minutes, in an ambulance for 12 more, and then ED staff worked for another 23. They could not save him. He was 28.

Following an investigation into this line-of-duty death, the National Institute for Occupational Safety and Health (NIOSH) issued a series of recommendations designed to help the firefighter's department and others avoid similar incidents. While recognizing that cardiac deaths may not always be predictable or preventable, investigators suggested the following steps to help reduce their likelihood:

Consider modifying the medical evaluations of firefighters, both before hire and after, for consistency with NFPA 1582.

The department in question conducted physicals that on some counts exceeded the requirements of 1582. The only component of 1582 it didn't meet was the standard's recommended exercise stress test (EST) to screen for obstructive coronary artery disease (CAD) in firefighters over 40. However, ESTs are known to have problems with false results, especially among young subjects who are, as this firefighter was, asymptomatic for CAD. The 2000 version of the standard, which was applicable at the time, did not recommend a routine resting EKG during preplacement screening, which might have detected the firefighter's enlarged heart.

The 1582 standard, formerly Medical Requirement for Fire Fighters and Information for Fire Department Physicians, was revised in 2003, and its title changed to Standard on Comprehensive Occupational Medical Program for Fire Departments. Content changes include more information on return-to-duty rehabilitation and additional references to the International Association of Fire Fighters' and International Association of Fire Chiefs' Fire Service Joint Labor Management Wellness/Fitness Initiative.

Ensure personnel are cleared for duty by a physician knowledgeable about the physical demands of firefighting and the components of NFPA 1582.

As many private physicians are unfamiliar with the tenets of 1582, NIOSH recommends fire departments not automatically accept a clearance to return to work by an employee's private physician. Department physicians, it says, should have the final decision after reviewing input from the private physician and others.

Enhance current wellness/fitness initiatives.

NFPA 1500 (Standard on Fire Department Occupational Safety and Health Program) and 1583 (Standard on Health-Related Fitness Programs for Fire Fighters) require departments to have wellness programs. Studies suggest such programs are cost-effective, reducing sick days and on-the-job injuries. This department was considering enhancements to its program, which NIOSH urged be fully implemented.

The death of the firefighter in question was attributed to hypertrophic cardiomyopathy (HCM)—his heart weighed 565 grams (normal is less than 400), with both ventricles thickened. He had no family cardiac history, had never complained of cardiac symptoms, and in fact had worked out at his station earlier in his shift. He had passed all departmental examinations and screenings. HCM is rare, and its patients usually asymptomatic. Its first clinical manifestation is often death. For these reasons, NIOSH concluded, his department cannot be blamed for this provider's demise. "It is unlikely," investigators wrote, "the fire department could have prevented this firefighter's untimely death." Its recommendations, it says, concern only "potentially relevant issues to this FD." They may, however, prove relevant to other departments as well.

The entire report can be viewed at www.cdc.gov/niosh/firehome.html.