By D. BRADY ROGERS
With the recognition of the short- and long-term impacts of concussions, especially in sports, and given the rigors and hazards to which firefighters are exposed, the fire service has a lead to follow. A concussion, as defined by the Centers for Disease Control and Prevention (CDC), is a type of traumatic brain injury (TBI) caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth. This sudden movement can cause the brain to bounce around or twist in the skull, creating chemical changes in the brain and sometimes stretching and damaging brain cells. Repeated mild TBIs occurring over an extended period can result in cumulative neurological and cognitive deficits. Repeated mild TBIs occurring within a short time (hours, days, or weeks) can be catastrophic or fatal.
The October 2017 National Fire Protection Association (NFPA) United States Firefighter Injury Report—2016 listed 62,085 firefighter injuries in the United States. The NFPA noted that 21 percent of the reported injuries were falls, jumps, or slips, all leading causes of traumatic brain injuries. The U.S. Fire Administration (USFA) doesn’t track concussions or specific types of head injuries. It does track, through the National Fire Incident Reporting System (NFIRS), the parts of the body injured in fire-related firefighter injuries. In the Topical Fire Report Series issued in August 2016, Fire-Related Firefighter Injuries Reported to the National Fire Incident Reporting System (2012-2014), the head, neck, throat, and shoulder regions accounted for 26 percent of an annual estimated 29,425 fireground injuries. Another 4,125 injuries occurred responding to or from incidents. Slippery or uneven surfaces were the general contributing factor in fire-related firefighter injuries 25.4 percent of the time; an additional 16 percent were attributed to collapse or falling objects.
In reviewing the USFA’s Firefighter Fatalities in the United States in 2016, at least two fatalities were attributed to trips and falls, and another four were the results of being struck by debris.
A recent study by a Boston University research team suggests that repeated hits to the head, even those not resulting in a concussion and without the side effects of dizziness, headaches, confusion, or other symptoms, can still cause chronic traumatic encephalopathy (CTE), a neurodegenerative disease that leads to brain cell death, cognitive deficits, and dementia. The study focused on the origins of CTE and how it related to concussions and traumatic brain injuries. “To prevent the disease, you have to prevent head impact—it’s hits to the head that cause CTE,” said Lee E. Goldstein, MD, PhD, an associate professor and one of the study’s authors at Boston University School of Medicine and College of Engineering.
Personal Protective Equipment
The importance of wearing personal protective equipment cannot be overemphasized. According to the latest NFIRS data, only nine percent of reported fire-related firefighter injuries indicated a failure in gear as a factor in the injury.
In my research for this article, MSA Cairns Fire Helmet explained that testing requirements are not geared for concussions but are certified to meet NFPA 1971, Standard on Protective Ensembles for Structural Firefighting and Proximity Firefighting. Bullard also responded, saying that although there is no specific concussion protocol built into NFPA 1971, certification requires a series of acceleration drop tests. The helmet (complete with a mannequin equipped with multiple sensors) is dropped on all sides to make sure that the wearer’s head does not exceed a maximum acceleration value. The helmets are designed to absorb as much of the harmful impact and acceleration as possible.
As helmet designs continue to improve, it’s important to remember that NFPA 1851, Standard on Selection, Care, and Maintenance of Protective Ensembles for Structural Fire Fighting and Proximity Fire Fighting, states that structural firefighting ensembles, including helmets, should be retired 10 years from the date of manufacture.
Since 2006, the National Football League (NFL) has spent millions of dollars in research to improve helmet design. Continued research and improved technology with newer required standards in helmet design have reduced the severity of injuries, but there is no “concussionproof” helmet in existence at present.
Fire Service Testing/Protocols
To better measure the effects of potential line-of-duty traumatic head injuries, concussion baseline testing is now part of Fond du Lac (WI) Fire and Rescue’s fitness assessment. In an interview with Fox 11 News, Captain Jim Wamser explained that every firefighter must undergo baseline concussion testing. Pre- and post-injury testing will help the department’s medical director to evaluate on-the-job head injuries by comparative testing with the firefighter’s original brain health, which can be used as a guide to help determine treatment and recovery from a concussion.
According to the Mayo Clinic, concussion testing evaluates your brain’s processing and cognitive function after a head injury. A baseline concussion test shows how well your brain is functioning and may be useful in diagnosing a concussion after an injury. A health care provider may perform the test by asking questions, or testing may be done by computer.
Using sports medicine practices as a guide, the fire service can establish concussion protocols to prepare command, safety, emergency medical services, and other personnel for times when it becomes necessary to take firefighters out of the game. Observation becomes as important as evaluation. The mechanism of injury itself should require an assessment, even if the injured person is displaying an “I’m fine” attitude. It is easy to say and harder to do. Firefighters don’t want to be taken out of the game; they may even deny injury or its initial effects. The fact is that coaches don’t want to pull a player out in the middle of a game either.
In a proactive move, the Henrico County (VA) Division of Fire is planning to implement concussion protocols. Responding to an International Association of Fire Chiefs KnowledgeNet request, Chief Tony McDowell advises that his department’s objectives include the following:
- Provide annual department education on the signs and symptoms of concussions, current research, and the risks of ignoring symptoms.
- Establish benchmarks to pull firefighters for an evaluation sideline test—i.e., Maydays, collapses, falls, motor vehicle collisions, and resulting signs and symptoms.
- Implement on-scene baseline/sideline testing, specifically the King-Devick test, for accurately and objectively removing a firefighter from duty for further evaluation. This test, McDowell says, can be given on scene by a trained member with an iPad in two minutes. In association with the Mayo Clinic, the King-Devick test is a remove-from-play sideline screening tool that is quick, validated, and objective in detecting concussions. It has been used in collegiate sports, the National Women’s Hockey League, the National Hockey League (NHL), Major League Soccer, and other leagues.
In Henrico County, a firefighter suspected of having a concussion is removed from duty for a minimum of 24 hours per “Consensus statement on concussions in sport: the 4th International Conference on Concussion in Sport, Zurich 2012.” Firefighters diagnosed with a concussion should be referred to clinicians that specialize in concussion management—i.e., concussion clinics.
CDC Guidelines: Return to Play
Sports medicine experts provide models for determining when firefighters can return to duty—or, in the sports vernacular, return to play. Various sports, states, and programs have different protocols; the CDC has collaborated with multiple organizations and experts to develop clinical guidelines and tools for diagnosis and management of patients with mild TBI. Among them are its return-to-play progression guide. The CDC has worked with a health care professional to establish five steps for safely returning an athlete to play.
As the baseline step of the Return to Play Progression, the athlete needs to have completed physical and cognitive rest and be free of concussion symptoms for a minimum of 24 hours. Keep in mind that the younger the athlete, the more conservative the treatment. To progress to the next step, the athlete needs to be able to accomplish the task without symptoms.
Step 1: Light aerobic activity
- The Goal: Only to increase heart rate.
- The Time: 5 to 10 minutes.
- The Activities: Exercise bike, walking, or light jogging. No lifting, jumping, or hard running.
Step 2: Moderate activity
- The Goal: Limited body and head movement.
- The Time: Reduced from typical routine.
- The Activities: Moderate jogging, brief running, moderate-intensity stationary biking, and moderate-intensity weightlifting.
Step 3: Heavy, noncontact activity
- The Goal: More intense but noncontact.
- The Time: Close to typical routine.
- The Activities: Running, high-intensity stationary biking, the player’s regular weightlifting routine, and noncontact sport-specific drills. This stage may add some cognitive component to practice in addition to the aerobic and movement components introduced in Steps 1 and 2.
Step 4: Practice and full contact
- The Goal: Reintegrate in full contact practice.
Step 5: Competition
- The Goal: Return to competition.
Depending on the injury and presenting symptoms, it may take several weeks to months to work through the five-step progression.
Since the goal is to return a firefighter to duty, these guidelines can be developed further and adapted to a firefighter’s job. In evaluating a firefighter’s brain health, it becomes apparent why Fond du Lac Fire and Rescue’s baseline concussion testing in fitness assessments becomes even more important and sets an example for other departments. Protecting firefighters is the priority. Conducting baseline concussion tests and instituting concussion protocols help to protect firefighters’ health and provide documentation for the department should a legal issue arise. Since the dangers of concussions and TBIs have become known, all 50 states now have “removal and clearance for Return to Play” laws for concussions in young athletes. Major League Baseball (MLB), following the examples of the NFL and NHL, has adopted concussion protocols. Instituted in 2011, the MLB’s policy includes seven days on the disabled list for concussions. Similar standards can be developed, adapted, and adopted for firefighters exposed to the risks of TBIs.
D. Brady Rogers, MPA, retired as a captain/shift commander with the Centerville-Osterville-Marstons Mills (MA) Department of Fire-Rescue after 37 years of service. He is a graduate of the National Fire Academy Executive Fire Officer program and a designated Chief Fire Officer.