Firefighters rarely die inside burning buildings, concludes Bill Carey, who researches line-of-duty-death (LODD) data. In “One Out of 93,” he reviewed the causes of firefighter fatalities in 2017. He found that although annual LODD rates have remained relatively constant, on-duty deaths in the areas where the highest performance is expected—such as advancing hoselines inside burning structures—are declining.1 In a later article, Carey reported that in 2017, zero firefighters died while advancing hoselines inside burning structures.2 The striking conclusion is that firefighters are dying by causes other than fire behavior and building collapse.
Although LODD numbers are decreasing, the data implicating an increase from other causes is concerning. This article explains the need for multifaceted wellness programs that address aerobic fitness, mental health, recovery, nutrition, and sleep. These interconnected areas contribute to cardiovascular disease risk and are factors in psychological distress and increased injury incidence. By implementing preventive strategies such as risk screening, exercise training, and sleep hygiene, we can reduce LODDs. It’s a shame that we are consistently losing firefighters to illnesses that can be mitigated if detected and addressed early. Experience and research suggest that influential leadership with deliberate effort to inspire subordinates to place priority on overall wellness will produce better habits that will reduce LODDs.
Since 1995, nearly half of all on-duty fatalities have been linked to sudden cardiac death. Firefighters experience disproportionately higher rates of cardiovascular events (CVEs) than individuals in other occupations, including police officers.3 Although the high prevalence of obesity and physical inactivity has contributed to the cardiovascular events in the fire service, a plethora of research conducted in 2016 and 2017 revealed a few other significant factors contributing to these staggering statistics. Sleep hygiene is just one of these factors.
(1) Firefighters work through a five-station circuit (four rounds at 45 seconds per station) to build muscular endurance. The firefighter at left performs sandbag cleans; in the middle, curls; and at right, a hand release pushup. (Photos by Mike Legeros.)
Firefighters require high levels of aerobic fitness to safely meet the heavy work demands of the job. Failure to maintain aerobic fitness creates a mismatch between ability and demand, which may trigger a CVE. The most widely recognized approach to improving firefighter wellness is the adoption of a wellness and fitness program. Although several groups have advocated for mandatory wellness and fitness programs for more than three decades, only 30% of United States fire departments have implemented such programs.4
Efficacy of Wellness Programs
In addition to reducing LODDs, wellness programs also reduce the costs of work-related injuries and illnesses. According to data reported by fire departments to the National Fire Protection Association (NFPA), about one-third of the nation’s more than one million firefighters sustain a work-related injury each year.5 The National Institutes of Health conducted one example of a successful program to counter this trend, the PHLAME (Promoting Healthy Lifestyles: Alternative Models’ Effects). The study found that firefighter health promotion programs designed to improve physical activity, fitness, and nutrition habits were associated with a reduction in workers’ compensation claims and medical costs.5 In fact, results of the program found an 8% reduction in the number of claims among the PHLAME fire departments, compared with a 13% increase in the number of claims among the comparison departments with no wellness program.5
Despite such proven evidence, fire departments are reluctant to implement wellness programs. Implementation costs, liability, and lack of knowledge are commonly cited reasons for their reluctance.5 Another reason for the failure to implement these programs may be that there’s no formal collaboration between fitness organizations and the fire service.4 The Wellness Fitness Initiative recommends that peer trainers work under the direction of professional exercise specialists. Fire service administrators at all levels lack the guidance and knowledge to make informed decisions on wellness programs.3
Stress and Firefighter Well-Being
Complicating the equation are the job’s impacts on the mind and immune system. Recent research has found that stressors encountered by firefighters have an impact on psychological well-being.6 In fact, organizational factors may play a role as strong as or stronger than the traumatic stressors inherent with call responses.6 These organizational factors include sleep disturbances, exposure to hazardous materials, and inactivity. Of those factors, sleep disturbance is a major contributor, for psychological and physiological reasons. Untreated sleep disorders are high risk for cardiovascular disease, cancer, post-traumatic stress disorder (PTSD), memory regulation, and other metabolic disorders. Chronic sleep deficiency leads to a constant state of fight or flight and is expressed with the inflammatory process that inflicts havoc on the immune system and hormone levels.
Relationship with Sleep, Shift Work, and Illness
A causal relationship has been found between insomnia and both obesity and suicide. People who sleep fewer than four hours a day have a suicide rate 3.5 times higher than those who sleep six to eight hours a day.7 In shift workers, increased incidences of cardiovascular disorders, peptic ulcers, and reproductive dysfunction are well-known, and all contributed to sleep disorders.7 Shift work is also strongly linked with cancer; it is now classified as a probable carcinogen.7 Unfortunately, because most people don’t realize sleep disorders are common, costly, and treatable, many remain undiagnosed and untreated.8
Just one reason these disorders have become common is the increased use of electronic devices at night. In 2013, the American Medical Association issued a warning report that attributed certain cancers, obesity, diabetes, and psychiatric disorders to disruption of circadian rhythmicity from the use of electric light at night.9 The shifts firefighters work further compound the disruption of the circadian rhythmicity and are a noted concern.10 Working frequent extended shifts and long workweeks leads to sleep deficiency and misalignment of circadian phase, which disrupts nearly all functions and cycles operating in the body.8
Shift Work and Major Depressive Disorder
Sleep disorders are a well-known risk factor in terms of mood disorders, particularly major depressive disorder (MDD).7 Melatonin, the hormone that governs sleep, is a key regulator to the circadian signal, and numerous studies have found lower melatonin levels in MDD.7 MDD has been strongly linked to suicide, and recent findings suggest that a firefighter is three times more likely to die of suicide than in the line of duty.11 In addition, 90% of depressed patients complain of sleep disorders and insomnia.7 Abnormalities of rapid eye movement (REM) sleep are considered to be specific to MDD and connect shift work with depression.7 Compared to all disorders associated with suicide, MDD confers the greatest risk.12 Although lifetime rates of MDD are 17%, the suicide rate among people with MDD is 20 times higher than for a person without the disorder.12 Simply stated, shift work negatively impacts length of sleep, quality of sleep, and mood. Sleep difficulty and insomnia are confirmed risk factors for depression and suicide.11
(2) Firefighters work on range of motion and flexibility as a cool-down to an exercise session.
Because firefighters must work night shifts, changing work schedules has been proposed as a means to improve sleep patterns and well-being. The ideal schedule is the 24-hour-on, 72-hour-off shift.13 This schedule incorporates a sufficient recovery period and eliminates the mandatory overtime that most firefighters work based on their 56-hour workweek. However, this schedule requires hiring additional personnel and is initially more costly to local governments. To successfully implement the 24-hour-on, 72-hour-off shift, fire departments would have to hire and staff a fourth shift. In the long run, this fourth shift would produce cost savings because it would eliminate mandatory overtime.
An alternate schedule for local government is 48 hours on/96 hours off vs. the Kelly schedule (the most common in North America), which provides only 24 hours off duty between shifts.14 Although most agencies were hesitant to implement the 48/96, once implemented, none returned to previous schedules.14 Research determined that the 48/96 schedules could reduce burnout.14 This research also found that one to two nights of recovery sleep are required to recuperate from deficits caused by a 24-hour shift. Although this study found no significant changes in health habits with the new schedule, the authors recommended that future studies examine how shift schedules impact rates of exercise and food choices as a means to reduce cardiovascular disease.14
A more recent national study of 7,000 firefighters conducted across 66 fire departments found that 37% of firefighters were at risk of a sleep disorder and that 81% of that cohort had not yet been diagnosed.8 This study included educational and treatment components. Despite the free treatment, only 16.3% of those who screened positive for the risk took advantage of treatment.8 Of equal concern as the numbers of undiagnosed sleep disorders is the lack of interest in treatment. More emphasis on education may help firefighters recognize the dangers of these disorders and their biological need for sleep.
Most study participants attended the educational sessions that included strategies to improve sleep hygiene, such as reduction of unnecessary light and noise in dorms, reduction of blue light prior to sleep, and the use of caffeine and effective napping to promote alertness.8
In addition to the reduction in firefighter injuries, the study found that a department of 1,200 active firefighters could save approximately $2.1 million annually in time lost from disability and sick hours.8 Although there is no other published study that evaluates the impact of sleep hygiene on firefighter injuries through evaluation of sleep health-related intervention, a similar large-scale program for truckers showed that truck drivers with untreated sleep apnea had a five times higher rate of preventable crashes than those who were not diagnosed with the disorder.8 Truck drivers are similar to firefighters in that they work long hours and are exposed to dangerous conditions.
How to Effect Change
Based on the aforementioned information, it is apparent that organizational factors inherent to firefighting can lead to sleep disorders, cancer, and cardiovascular disease. Often, these factors interrelate and further complicate other areas of health, such as mental health. As demonstrated by the data, firefighter LODDs are more commonly associated with health conditions that can often be mitigated. Implementing preventive strategies involving risk screening, exercise training, and sleep hygiene should lead to reduced LODDs. Fire departments should implement multifaceted wellness programs that screen members for cardiovascular disease and sleep disorders while also providing them with education on improving fitness and diet.
Local departments must focus on strategies that encourage fitness professionals to become engaged with their department. Although these programs are costly to implement, several studies have determined their efficacy at reducing injury, CVEs, and death while also being cost effective in the long run. O2X is an organization that provides workshops to address mental and physical health. Its mission is to maximize human performance through world-class training and education. Agencies using such programs have found a 33% reduction in costs related to cardiovascular disease and a 23% reduction in cancer-related costs.15
Implementing a health and wellness program is not enough. Organizational factors must encourage participation, and members must become educated in a way that inspires positive change. The fact that more firefighters die in the line of duty because of poor health is a key indicator that we must target conditions that lead to poor health rather than individual behavior.
In his January 2018 editorial on confronting cancer in the fire service, Fire Engineering Editor in Chief Bobby Halton asked, “If we are serious about firefighter health and safety, rather than blaming, measuring, punishing, and rewarding, what if we focused on increasing our educational efforts, improving our troops’ knowledge, and giving them the proper tools and equipment at the right time?” He added: “Behavior modification isn’t the answer; we must fix the system.” He challenged leaders within the fire service to focus their efforts on fixing the conditions that lead to poor health.16
Improving Health Among Firefighters
Policies demanding compliance are not the answer. Fire service leadership must become educated on the pathophysiology of disease processes and inspire their members to become engaged in better wellness behaviors. Enhancing leadership knowledge and participation should be the focus of policies aimed at a reduction of LODDs. For years we have admitted to the need for better nutrition and regular exercise among firefighters. Now we know that sleep deficiency is linked to developing health conditions such as hypertension, obesity, diabetes, and mental health disorders. The evidence is clear: Restorative sleep is necessary for optimal brain function and total health.17 In fact, restorative sleep has been found to serve as a protective factor against PTSD while sleep deficiency can increase the risk for developing PTSD.17 We must ensure that wellness programs incorporate an understanding of the factors surrounding sleep and overall wellness. Focusing solely on physical fitness and nutrition neglects a critical component of overall wellness.
The military has found that sleep is an important contributor to physical, mental health, and operational readiness.18 In response, they have established several programs aimed at treating and preventing sleep disorders and promoting healthy sleep practices.18 Historically, in military and civilian populations, poor sleep was seen as a symptom of other conditions instead of a primary disorder. 18 It is now well understood that sleep may precede the onset of many psychological and medical conditions and should be treated as a primary disorder.18 The barriers for achieving healthy sleep for military service members mirror those present in the firefighting population. These barriers include cultural, operational, knowledge-related, and medical system barriers that impede efforts to promote sleep health and treat sleep disorders 18
Generally, cultural attitudes have tended to undermine the importance of sleep. There is a negative stigma associated with expressing a greater need for sleep. This stigma results in failure to acknowledge and seek help for sleep problems prior to manifestation of chronic and debilitating disorders.18 Firefighters are often targeted for pharmaceuticals designed to solve sleep disorders without realizing that these very medications lead to psychological disorders. Long-term use of medication for sleep disorders has been found to reduce the stages of REM sleep that are necessary for physiological restoration.17 Other side effects of these medications include impaired cognition, insight, and inability to achieve new learning. Nonpharmaceutical sleep hygiene practices are easy to learn and implement and can help reduce the prevalence of sleep disorders. It is well understood that sleep has a direct influence on mental and physical health and cannot be omitted when considering a healthier workforce.
Wellness programs must also incorporate medical screenings that provide measurements to ensure members are able to perform their essential job functions, provide a member insight to their fitness level, and encourage them to improve. More importantly, these evaluations provide referenced screening tools that can detect serious medical conditions early.19
A medical professional who understands the demands of firefighting should conduct the screenings. Screenings are costly initially, but in the long run, they lead to significant cost savings by preventing disability and LODDs. Research by Professor Denise Smith, PhD, Skidmore College, found that for every LODD, there are 17 nonfatal cardiac events among firefighters on duty.19 Medical screenings have the potential to identify cardiac abnormalities and certain cancers before they become deadly.
Data comparing three large metropolitan fire departments found that the two departments that were compliant with National Fire Protection Association (NFPA) 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments, and with NFPA 1583, Standard on Health-Related Fitness Programs for Fire Department Members, and had established a wellness fitness initiative had no cost incurred or money paid to date for disability. On the other hand, the department with no wellness program or medical evaluations in place incurred 167% more in costs and paid 141% more in disability than the departments with a wellness program. It is clear that these programs save lives and money in the long run.
Wellness in the fire service is a difficult and complex cultural phenomenon that requires intrinsic motivation. As Halton says, this is best done in an environment where leadership support is present.16 Proper equipment, education, and time must be available. The leader who models desirable behavior and creates an environment that inspires wellness will see the greatest results. Leaders must recognize the importance of and facilitate safety naps, fitness activities, and better nutrition.
Even without the ability to offer screenings to all employees, inspiring them and allowing them to take care of themselves will produce favorable results. Including sleep disorder evaluations and medical screenings will help identify problems early, further reducing LODDs.
Previous research and evaluation have already proven the effectiveness and cost savings of these screenings. What has not yet been evaluated is the effectiveness of leadership influence on behavior. In line with Halton’s recommendations, we must not focus on individual behavior; instead, we must focus on the system by creating an environment that increases educational efforts, expands knowledge, and gives our people every opportunity to succeed. Influential leadership with deliberate effort to inspire subordinates to place priority on overall wellness will produce better habits that will lead to a reduction of LODDs.
The University of North Carolina Study
The University of North Carolina at Pembroke recruited online, with the approval of its internal IRB, a total of 1,369 career and volunteer firefighters from a large sample of current firefighters to participate in a Web-based survey that evaluated firefighter wellness as a means of reducing LODDs. (The raw data is available through Qualtrics or by e-mailing me at email@example.com.)
Participation was voluntary. This sample population included firefighters from several reputable fire service organizations including the Florida Firefighter Health and Safety Collaborative and the North Carolina State Firefighter Association. The next phase of this study will evaluate and analyze data from a random sample of members from several career agencies.
Seeking data through a voluntary convenience sample may produce response bias. However, a large enough sample should help to identify trends for this initial survey. The study also has some limitations because of its broad focus. The number of questions within each health domain was limited because of the large number of topics the survey covered.
The data was collected through self-report measures and, thus, could be subject to participant biases. Despite the limitations, the current study had a number of strengths that will make it an important contribution to the scientific literature. For instance, this study is the first large-scale study focused on ascertaining the perspectives and experiences of total wellness to include sleep and mental health in a national sample of firefighters.
This pilot study included 1,369 responses: 61% career, 12% volunteer, 25% combination department, and 2% wildland and military firefighters; 91% of the respondents were male, 9% were female; a great majority were white (95%). Examination of the data revealed the following:
- 60% of respondents reported that their supervisors encouraged participation in fitness.
- 41% had supervisors who led by example with regard to wellness.
- 32% were allowed to take safety naps on duty.
- 7% had received education on sleep hygiene.
- 36% consistently exercised while on duty.
- 18% averaged more than seven hours of sleep a night.
- 64% averaged between five and seven hours of sleep a night.
- 18% averaged fewer than five hours of sleep a night.
- 78% reported bouts of sleep difficulty.
- 31% reported sleep difficulty most nights.
- 24% had been diagnosed with hypertension by a medical professional.
- 36% had been diagnosed with elevated cholesterol levels by a medical professional.
- 17% had been diagnosed with depression by a mental health clinician.
- 10% had been diagnosed with PTSD by a mental health clinician.
- 70% reported consuming less than three drinks a week (20% were abstinent).
- 45% were provided with both medical and cardiovascular screenings.
- 32% were provided with only medical physicals.
- 18% were not provided with any type of medical screenings.
- 23% reported thoughts of suicide at some point in their career.
- 5% reported that they had made a plan for suicide at some point in their career.
- 2% reported that they had made a suicide attempt during their career.
Interpretation of the Data
The survey was promoted as solely addressing the wellness factors that affect LODDs. Questions pertaining to mental health were included in hopes of finding results from individuals not directly targeted through the study title—ergo, a technique to reduce bias. The results found that firefighters did not experience higher rates of depression, suicidal ideation, plans, or attempts as compared to the general population; 10% of respondents reported diagnoses of PTSD by a mental health professional. This is notable, because this number mirrors previous large-scale findings20 published in a meta-analysis of the worldwide current prevalence of PTSD in rescue workers that found that out of 28 studies, there is approximately a 10% rate of full PTSD.20
Of concern were the findings that only 18% of respondents reported sufficient sleep and 7% had received sleep hygiene education by their agencies. Additionally, less than half of the respondents reported that their departments provided them with both a physical and cardiac stress testing. Optimistically, though, 70% of respondents reported that their supervisors had a good attitude toward wellness and that 60% of their supervisors encouraged participation in fitness.
Although firefighter LODDs in operational areas are where the highest number is expected, the number of annual LODDs has remained relatively constant. We are losing firefighters to progressive physical and mental health conditions that are generally preventable if addressed early. This article suggests that by implementing preventive strategies involving risk screening, exercise training, and sleep hygiene, we could reduce deaths through improved wellness. A key to accomplishing this lies within the frontline leaders and their ability to inspire, educate, and encourage.
BMC Cardiovascular Disorders
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5. Kuehl, KS, Elliot, DL, Goldberg, L, Moe, EL, Perrier, E, & Smith, J. (2013). Economic benefit of the PHLAME wellness programme on firefighter injury. Occupational Medicine,63(3), 203-209.doi:10.1093/occmed/kqs232.
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8. Sullivan, J, O’Brien, C, Barger, L, Rajaranam, S, Czeisler, C, & Lockley, S. (2017). Randomized, Prospective Study of the Impact of a Sleep Health Program on Firefighter Injury and Disability. Sleep, 40(1), 1-10. doi:10.1093/sleep/zsw001.
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10. Jahnke, SA, Poston, WS, Jitnarin, N, & Haddock, CK. (2017). “Health, Wellness, and Readiness in the Fire Service.” International Fire Service Journal of Leadership & Management. Issue 11, 7-13.
11. Savia, JS. (2008) Suicide among North Carolina professional firefighters: 1984-1999. Dissertation Abstracts International, 69, 1-59.
12. Joiner, TE, Jr, Van Orden, KA, Witte, TK, & Rudd, MD. (2009). The interpersonal theory of suicide: Guidance for working with suicidal clients. Washington, DC, US: American Psychological Association. Http://dx.doi.org/10.1037/11869-000.
14. Caputo, LM. et al.. (2015). The impact of changing work schedules on American firefighters’ sleep patterns and well-being. Signa Vitae – A Journal in Intensive Care and Emergency Medicine,10(1), 25-37. doi:10.22514/sv101.042015.3.
15. O2X Human Performance Web site. https://o2x.com/.
16. Halton, B. (2018, February 1). Walking the Walk. Fire Engineering, 171(2), 8-8.
17. Brown, CA., Berry, R, & Schmidt, A. (2013). Sleep and Military Members: Emerging Issues and Nonpharmacological Intervention. Sleep Disorders, 2013, 1-6. doi:10.1155/2013/160374.
18. Troxel, WM, Shih, RA, Pedersen, ER, Geyer, L, Fisher, MP, Griffin, BA, Steinberg, PS. (2015). Sleep in the Military. Rand Health Quarterly,5(2), 1-12.
19. Kerwood, SD. (2017). The Emergency Services Road Map to Health and Wellness (pp. 1- 27,Publication). Fairfax, VA: Safety, Health, and Survival Section of the International Association of Fire Chiefs.
20. Berger W, et al. (2011). Rescuers at risk: a systematic review and meta-regression analysis of the worldwide current prevalence and correlates of PTSD in rescue workers.” Social Psychiatry and Psychiatric Epidemiology, 47(6), 1001-1011. Doi: 10.1007/s00127-011-0408-2.
DENA ALI is a captain with the Raleigh (NC) Fire Department. Previously, she was a police officer in North Carolina for five years. Ali is a founding member of the Carolina Brotherhood and founder and director of North Carolina Peer Support. She has a master’s degree in public administration from the University of North Carolina at Pembroke; her research focused on firefighter suicide. She has an undergraduate degree from North Carolina State University. She teaches a class on suicide prevention at FDIC International.