By Michael Hamrock
Unstable angina and acute myocardial infarctions are now classified as acute coronary syndromes (ACS). A recent review of injuries in the Boston (MA) Fire Department revealed that a Boston firefighter suffers an ACS every three weeks. In addition, a Harvard Pilgrim Health Care study discovered that 79 percent of Boston firefighters have elevated blood pressures. If these troubling statistics persist, it is estimated that over the next eight years nearly 10 percent of active firefighters will experience an acute coronary event.
A predictable and harmful physiological cascade of events occurs during fire operations that place firefighters at very high risk for acute coronary syndromes. “Jake” is a 55-year-old Massachusetts firefighter with 29 years of experience on a ladder company. He has a history of hypertension and recently gained 15 pounds since undergoing job-related knee surgery. Jake is recovering from an ACS that occurred while he was performing search, rescue, and overhaul operations at a fire in a triple-decker. There is much to learn from this case study about the mechanism of ACS in firefighters and the importance of having a healthy and fit fire force capable of withstanding the extreme physical, mental, and chemical stresses of the job.
The Stress Response
The following is the chain of events that triggered Jake’s cardiovascular crisis. At 2:00 a.m., he was awakened by the firehouse alarm to respond to a building fire with occupants trapped. He immediately experienced a rapid, strong heartbeat as a result of the release of adrenaline, cortisol, and other stress hormones. This surge of hormones, known as the “fight or flight” response, further strained his cardiovascular system by increasing his blood pressure and his respiratory rate and narrowing his coronary arteries.
There are also the physical demands of the job. Wearing heavy, bulky, and poorly ventilated bunker gear in this hot and smoky building put a tremendous strain on Jake’s heart. Compounding this was the workload from carrying 70 pounds of tools and breathing apparatus while operating at this fire. Under these conditions, Jake’s body temperature most likely exceeded 101°F. His blood pressure and heart and respiratory rates became more dangerously elevated as he broke open doors and ran up three flights of stairs in near-zero visibility to search for fire victims. Despite feeling physically drained and worn after reaching the fire floor, he spent the next 20 minutes pulling down walls and ceilings to check for fire spread. These efforts placed even greater strain on Jake’s cardiovascular system.
Another important contributor to cardiovascular stress are the toxic products inhaled and absorbed at a fire. Heat, smoke, toxins, carbon monoxide (CO), and hydrogen cyanide (HCN) cause immediate and long-term damage to the cardiovascular system. Inhaling the CO and the HCN from even a one-room fire has the potential to become rapidly lethal by interfering with oxygen transport to the cardiac cells. The acute and chronic exposure to the by-products of combustion from a typical house fire directly damaged the inner lining of Jake’s coronary arteries. This stimulated a detrimental inflammatory response of white blood cells, platelets, and other “sticky” substances that formed a scab on the injured vessel wall. Eventually, fatty deposits, cholesterol, and calcium adhered to this site, leading to plaque buildup and subsequent coronary artery disease. This formation of “clogging” and narrowing of the coronary arteries impeded blood flow to Jake’s heart muscle during physical exertion.
There is a psychological aspect that also compromises Jake’s cardiovascular health. The chronic mental stresses of anticipating calls, sleep deprivation, and a career of witnessing suffering and traumatic events continue to incite a steady release of stress hormones into Jake’s bloodstream. Persistent exposure to these stress hormones contributes to injury and inflammation of his cardiovascular system, leading to premature coronary artery disease.
Jake’s Acute Coronary Event
Shortly after returning to the firehouse, Jake became very sweaty and developed severe jaw and left arm discomfort. The extreme physical, chemical, and mental stresses on the fireground caused an underlying coronary artery plaque to fracture and dislodge. Pieces of this plaque then traveled downstream in the coronary artery, forming a clot and obstruction which precipitated his heart attack.
Jake was immediately given an aspirin and oxygen and transported to a local hospital, where he was diagnosed with an acute coronary syndrome. He had an emergent cardiac catheterization that revealed a 99-percent blockage to a major coronary artery. This was followed by a successful angioplasty and a stent was placed in this obstructed vessel. Although fortunate to survive, he will not be able to return to firefighting duties since his heart muscle was damaged as a result of fighting this fire.
Firefighters are at very high risk for coronary artery disease because of the physical, chemical, and mental stresses of the job. A firefighter with any underlying cardiac risk factors is particularly vulnerable to an ACS on the fireground. The fire service needs to do a much better job of prevention to reduce the incidence of ACS in firefighters. This can be accomplished by developing firefighter wellness programs that incorporate health screenings and fitness training. Firefighters should undergo comprehensive and confidential annual physicals that emphasize heart disease risk reduction. These exams should include aggressive screenings, treatment, and close follow-up care for hypertension, elevated cholesterol, diabetes, excess weight, and smoking.
Firefighters should participate in a yearly physical ability test to ensure that they are healthy and fit enough to withstand the tremendous demands of the fireground. Firefighters need to become more proactive with their physical conditioning and model the same diet and training program as professional athletes. The physical efforts expended on the fireground can be even more demanding than playing in any competitive sport. An aerobic and core muscle strengthening and endurance workout program should be incorporated into the daily routine for all firehouses. A firefighter wellness program that incorporates the ideas and principles that “firefighters are athletes” will allow firefighters to do their jobs more safely and effectively and reduce heart disease in the fire service.
The “FIREFIGHTERS are ATHLETES” ACS Prevention Program
A. Annual Physical Exam and Physical Ability Test (PAT). The primary care physician (PCP) should regularly screen and intervene for heart disease risk factors. Starting at age 40, firefighters should undergo an exercise stress test every three years and discuss the efficacy of daily aspirin therapy with the PCP. This should be followed by firefighter participation in a “mini-training camp” PAT to ensure that they are fit and safe to do vigorous fire duty.
T. Train-the-Trainer Program. Train at least one firefighter in every firehouse to act as a certified fitness instructor to ensure that all members are working out safely and reaching their fitness goals. All new recruits could be trained as fitness instructors during each fire academy class for a minimal cost and time.
H. Hydration and On-Scene Rehabilitation. A dedicated unit should respond to all fires to ensure that firefighters are well hydrated and cooled down and evaluated for heat exhaustion before reentering the fire building.
L. Lifestyle Changes. Fire officers need to set better examples and function more like “coaches” to instill more pride and professionalism in the job and encourage firefighters to develop better self-care habits. The fire service should expect that firefighters will remain healthy and fit throughout their careers.
E. Educate for Safety. Training drills must focus more on the importance of full compliance with regard to using self-contained breathing apparatus (SCBA) to prevent HCN and CO inhalation exposures. These sessions should include more education on the early recognition of the signs and symptoms of an ACS and avoiding “denial” behavior. Firefighters also must understand that the cardiovascular strain and risk for an ACS can persist for up to 48 hours after battling a fire. Seminars on smoking cessation should also be offered.
T. Training Time. Set aside at least 45 minutes each shift to allow all firefighters to partake in a stretching, aerobic, and muscular strengthening and conditioning program. Firefighters need to workout at least four times a week to maintain adequate fitness levels for the job.
E. Eating Habits. Develop a healthy nutrition program that emphasizes the need for better portion control and meals that contain more fruits, vegetables, and fish and less saturated fats, meats, and salt. The faculty and students from the local university nutrition programs could be recruited to assist in this endeavor.
S. Stress Reduction. Develop ongoing training classes to help firefighters develop effective coping skills to deal with the mental stresses of the job and the effects of the stress response. This should include instruction in effective breathing exercises, positive visualizations, eliciting the “relaxation response,” avoidance of self-medication behavior with alcohol and drugs, and better use of the critical incident stress management (CISM) teams and employee assistance program (EAP) referrals.
Jake’s devastating cardiac event likely could have been prevented if he was involved in a firefighter wellness program. Fortunately, the Boston Fire Department has just kicked off its “Firefighters are Athletes” (FAA) program to improve the health and fitness of Boston firefighters and prevent heart disease and injuries. It is now time to encourage other fire departments in Massachusetts and around the country to join in these FAA programs. Cities and towns that adopt these recommendations will have a healthier, safer, and more fit fire force. In the long run, FAA programs will save taxpayers millions of dollars in injury, disability, and overtime costs, and more importantly, will save the lives of many firefighters.
Dr. Michael G. Hamrock, MD is a marathoner and former Boston firefighter. He is the medical examiner for the Boston Fire Department and a primary care physician at Caritas St. Elizabeth’s Medical Center. He is an active member of the Boston Fire/Metro Fire CISM Team.