LODDs: More Immediate Medical Assistance for Firefighters Who Collapse During and After Fighting a Fire

By Mary Jane Dittmar

Firefighter line-of-duty deaths (LODDs) have been increasing in responders who suffer cardiac arrest on the emergency scene or two or more hours after returning from the fireground. In the latter case, the firefighter may be in the fire station or at home. Investigation has found that a majority of these LODDs have been attributed to heart attacks/cardiovascular events.

These events have been of concern to the fire service, the government, and the medical, research, and educational communities for some time. Potential causes for this phenomenon have been discussed and include, among any others, preexisting conditions, family history, contaminants contained in smoke, lifestyle, sleep patterns and deficiencies, stress, overexertion, and dehydration. Various types of research studies have been and are being conducted in some of these areas.

Another approach to addressing this growing statistic among LODDs has been directed at delivering medical assistance to the firefighter as quickly as possible after he is found. The underlying question is, Can immediate medical intervention at the scene prevent any of these deaths?

In Firefighter Down: Treating Cardiac Arrest, for example, Lieutenant and EMT-intermediate Robert C. Owens Sr. recommends that saving our own and firefighter rescue training should go beyond locating and removing a downed firefighter. “There is no mention of caring for firefighters after rescue from the fire environment or when they collapse on scene or at the station,” he points out. He advocates that preparation on the fireground should include treating a firefighter in cardiac arrest.

“Now that we know the unique aspects of firefighter patient care, we must add those variables to our training program and begin to find ways to overcome them,” he advises. His advice: “Take your regular cardio-pulmonary resuscitation (CPR) mannequin and add turnout gear and self-contained breathing apparatus. Practice taking off turnout gear and self-contained breathing apparatus (SCBA) while wearing firefighting gloves, and then transition over to EMS gloves.”  Owens believes that “basic EMS skills will be the key to successful outcomes when a firefighter is down.” Owens’ article is at http://bit.ly/1JD6PRn.

Image courtesy of digitalart at FreeDigitalPhotos.net


The death of New Hanover County (NC) Captain David Heath from a heart attack while participating in a training exercise spurred Lieutenant Christopher Watford, BS, NRP, and Paramedic Michael Herbert, BA, NREMT-P, of Leland (NC) Volunteer Fire/Rescue to develop Firefighter Down: Special Consideration for the Resuscitation of the Downed Firefighter (http://bit.ly/1EIBtlV) The initiative includes a 10-step video that illustrates how to remove quickly the turnout gear of a firefighter who collapses on the fireground so that cardio-pulmonary resuscitation (CPR) can be begun as quickly as possible.

Watford and Herbert named the initiative FD-CPR, which stands for “Firefighter Down CPR.” They stress that crews must provide the highest level of care possible as soon as the firefighter is removed from the fireground. “What happens next is the key,” they explain.

Chest compressions cannot start until the downed firefighter’s gear has been removed. Watford and Herbert note that this can take a lot of time; the gear may be hot, wet, and possibly contaminated.

FD-CPR, they explain, shows responders how to stabilize the victim and begin CPR while the gear is still on. Watford says that the information (and training) can decrease the time it will take to administer chest compressions from eight to 10 minutes to four to five minutes.

The authors say the program requires minimal training and no additional equipment. “Every minute that an individual goes without chest compressions decreases survival about 10 percent,” Watford says.

Additional information about FD-CPR is at http://fd-cpr.com/. The Firefighter Down: CPR Project by Michael Herbert and Christopher Watford is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License. You can reach the authors at christopher.watford@lelandfirerescue.com and mike.herbert@lelandfirerescue.com


Episodes of Intense Anger Associated with High Risk of Heart Attack Within the Next Two Hours

Here is yet another factor that may be associated with a high risk of a heart attack within two hours. According to a European Society of Cardiology1 study, “The risk of heart attack has been found to be 8.5 times higher in the two hours following an acute episode of anger than during the ‘usual frequency’ patterns of anger.”

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The study involved 687 patients suspected of having suffered a myocardial infarction (MI, heart attack). They were initially assessed by coronary angiography2 at the Royal North Shore Hospital in Sydney, Australia, between the years of 2006 and 2012.  Of these patients, 313 were confirmed with occluded coronary blood flow and were enrolled in the study.

An elevated state of anger or anxiety preceded the MI and was also found to be significantly higher than at the same time the preceding day.  A report of the study was published in the European Heart Journal: Acute Cardiovascular Care, a journal of the European Society of Cardiology.3

The study’s authors cite a need “to consider strategies to protect individuals most at risk during times of acute anger.” Anecdotal experience and previous studies had suggested that anger can act as a trigger for MI.  

The finding itself may not be a big surprise to most of us: We are aware that stress is a factor in cardiovascular disease. That stress can be related to a multitude of areas: the job, the family, our daily schedules, our unique personality traits, and so on. What may startle some of us, however, is that the negative effects of an episode of anger can be immediate and that anger is a common emotion. The positive aspect here is that we can take steps to control our anger and thus reduce the threat it may pose for us.

Listed below are some of the study findings that might help us to come to terms with anger so that it does not have a major negative effect our cardiovascular system.

  • The study subjects self-assessed by questionnaire their anger level as evident over the 48 hours preceding the onset of symptoms. They used a seven-point scale in which “calm” was defined by 1 and “enraged, out of control, throwing objects, hurting yourself or others” was defined by 7. The threshold of acute anger was defined by level 5—“very angry, body tense, maybe fists clenched, ready to burst.”
  • Seven of the 313 confirmed MI cases (2.2%) had reached at least level 5 within the two hours preceding the onset of symptoms. One participant had reached anger level 5 within four hours of the MI, and two participants reported anger level 4 (“moderately angry, so hassled it shows in your voice”) within two hours of MI and three participants within four hours.
  • Based on the subjects’ usual frequency for anger, the relative risk of onset of MI symptoms occurring within two hours of reaching anger level 5 or above was calculated as 8.5 (95% CI 4.1–17.6), an eight-fold greater level of risk than that associated with normal levels.
  • Statistical associations with lower levels of anger or anger occurring over two hours before symptom onset did not reach statistical significance.
  • High levels of anxiety (greater than the 90th percentile on a validated anxiety scale) were associated with a 9.5-fold increased risk of triggering MI in the two hours after the anxiety episode when compared with anxiety levels of the previous day.
  • The investigators suggest that the findings in this study coincide with an “increased acceptance of the role of psychological factors, both acute and chronic, in the onset of acute MI, sudden cardiac death and stroke” and “are consistent with previous reports in other populations.”
  • Unlike most other studies, however, this study could confirm through  angiography, that the subjects had indeed suffered an MI and thus “adds to the small, but growing, body of evidence linking acute emotional triggers with onset of MI.”
  • The primary causes of subjects’ anger-triggered MI were arguments with family members and others, work anger, and driving anger. In other studies, arguments with family members and conflicts at work were the most frequent contributors.

Dr. Thomas Buckley, a senior lecturer and researcher from the University of Sydney and Royal North Shore Hospital, Sydney, said: “While the absolute risk of any one anger episode triggering a heart attack is low, our data demonstrate that the danger is real and still there.”  He explained that the increased risk of MI following intense anger or anxiety is “most likely the result of increased heart rate and blood pressure, tightening of blood vessels and increased clotting, all associated with triggering of heart attacks.”

Dr. Buckley advised that propensity to anger or anxiety should be assessed when managing an individual with heart disease or preventing heart disease in others. “It should be part of helping individuals to take care of themselves,” he said. “Potential preventive approaches may be stress reduction training to limit the responses of anger and anxiety or avoiding activities that usually prompt such intense reactions. And for those at very high risk, one could potentially consider protective medication therapy at the time of or just prior to an episode, a strategy we have shown to be feasible in other studies. Minimizing other risk factors, such as hypertension or smoking, would also lower risk.”

The full study, “Triggering of acute coronary occlusion by episodes of anger,” is at http://bit.ly/1BNeuIt. Dr.  Buckley can be reached at tom.buckley@sydney.edu.au.



  1. The European Society of Cardiology (ESC) represents more than 80,000 cardiology professionals across Europe and the Mediterranean. Its mission is to reduce the burden of cardiovascular disease in Europe.
  2. A well-established imaging test which reveals the condition of the coronary arteries. Blood flow and any blockages (occlusions) caused by the build-up of plaque can be identified by a dye released into the blood stream. A ruptured plaque, which blocks an artery, is the most common cause of MI.
  3. Buckley T, Soo Hoo SY, Fethney J, et al. Triggering of acute coronary occlusion by episodes of anger. Eur Heart J Acute Cardiovasc Care 2015; DOI: 10.1177/2048872615568969. The study was supported by University of Sydney and Royal North Shore Hospital.


Mary Jane Dittmar is senior associate editor of Fire Engineering and conference manager of FDIC. Before joining the magazine in January 1991, she served as editor of a trade magazine in the health/nutrition market and held various positions in the educational and medical advertising fields. She has a bachelor’s degree in English/journalism and a master’s degree in communicati


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