By Robert Owens
According to the Center for Disease Control (CDC), heart disease is the leading killer among all men and women in the United States. Some 385,000 Americans die annually from heart disease, with another 715,000 Americans reporting at least one heart attack each year (CDC, 2013). Although these statistics are alarming, there are inherent risks with being a firefighter that increase the potential for cardiac arrest.
According to Dr. Patrick Moriarty, Director of the Atherosclerosis and LDL—Apheresis Center at the University of Kansas Medical Center, a study of 77 firefighters with an average age of 39 years old revealed that most had the plaque buildup of a 52-year-old (Colwell, 2009). This was attributed to stress, sleep deprivation, and high-calorie meals.
Dr. Gregg C. Fonarow, a professor of medicine and associate chief of the cardiology division at the University of California—Los Angeles led a similar study of firefighters and found that particulates in fire smoke leads to inflammation of arteries, increasing the chance for heart disease or stroke (Colwell, 2009). The study also revealed that, despite an average firefighter age that would be considered “young,” the subjects’ arteries resembled those of people some 13 years older.
Dr. Jim Brown from Indiana University—Bloomington studied Indianapolis, Indiana, firefighters for six months, monitoring their heart rates. Findings included firefighters operating at 100 percent capacity of their hearts for hours, and high heart rates even during sleep not allowing their bodies to reach rapid eye movement (REM) and recover (Brown & Stickford, 2007).
As of this writing, the United States Fire Administration has recorded 16 line-of-duty deaths (LODDs) during 2014, with all but five being heart or cerebrovascular related. What does it all mean?
Simply, firefighters have heart attacks. This concept should be nothing new. The data have been there for years. These events occur at the station, after a shift, and even on the fireground. Although programs such as “Saving Our Own” or “Firefighter Rescue” training focus on calling a Mayday or locating and removing downed firefighters, there is no mention of caring for a firefighter after rescue from the fire environment or when they collapse on scene or at the station.
Just as firefighters face extraordinary factors that influence their potential to experience a heart attack or stroke, dealing with a firefighter in cardiac arrest is not a straightforward event; it takes different skill sets, procedures, resources, and composure to result in good outcomes.
One of the biggest obstacles we face when dealing with the firefighter cardiac arrest is his turnout gear and self-contained breathing apparatus (SCBA). To perform appropriate basic (BLS) and advanced life support (ALS) interventions such as defibrillation, intubation, vascular access, and medication administration, the gear must be removed. Although exposing the patient is normally a simple task, turnout gear makes it more complicated. If the firefighter has just been removed from a fire environment, the gear will be superheated, posing even greater challenges. A provider using his bare hands or even bare hands covered with emergency medical services (EMS) gloves will quickly move from being an EMS provider to a burn patient. Trauma shears, when used to cut the gear itself, may also be ineffective because of the durability and layering in the usual turnout gear ensemble. Fire gloves provide needed thermal protection but not the body substance isolation. When faced with the need to touch and remove superheated turnout gear, a layering technique of putting on EMS gloves and then fire gloves is recommended. Take additional care when removing superheated personal protective equipment (PPE) as not to inflict burns to the patient. This skill must be done rapidly but carefully. Once the PPE and SCBA are removed and ancillary heat is no longer an issue, the fire gloves can be discarded and the EMS gloves will already be in place, saving time in critical moments of patient care.
The average cardiac arrest requires an “all hands on deck” mentality, especially with all of the actions that must take place such as intubation, medication administration, vascular access, defibrillation, airway management, and documentation. Consider the event and add in the uniqueness of the patient being a firefighter; this adds a completely new dimension to the resource demands. Following are questions you need to consider beyond patient care techniques, and the answers to these questions will dictate additional actions you must take.
- Is the firefighter wearing PPE? If so, you will need to take the appropriate steps to remove it.
- Is this still an active scene? If so, you need to make the appropriate assignments and reassignments to ensure activities such as fire suppression and hazard mitigation continue. The company with the injured firefighter is no longer an available resource.
- How many ambulances are on scene? The fallen firefighter will be transported off of the scene by ambulance, regardless of the severity of the injury. This ensures not only that the best care is provided but it also removes the distraction created by a fallen member at an incident scene. Many departments issue an additional alarm at the initiation of a firefighter Mayday. Although this is good, EMS resources are sometimes not accounted for in these added alarm assignments. You need to account for EMS resources to maintain the capability to treat any additional firefighters. It is also recommended that you assign two ambulances to any significant incident; one to treat civilians and one to treat responders.
This may be the hardest thing to maintain during an event like this, but it is likely a key to successful outcomes. The incident commander (IC) and anyone participating in the treatment of the downed firefighter must maintain composure. Everyone will be asking questions and wanting to help. The look they see on your face and the tone they hear in your voice will often dictate if the scene returns to functioning or deteriorate into chaos. Isolation is a great tactic to use when trying to maintain your composure. Simply get in the back of the ambulance to provide a buffer between you and the rest of the incident; this will allow you to keep away everyone but the treatment team and prevent treatment by committee. This will also allow for rapid transport, if that decision is made, or, if ceasing resuscitation is warranted, it will isolate the victim from the rest of the incident scene. The body covered with the sheet is hard enough to view in a front yard; it will be multiplied ten-fold when it is the body of a colleague.
Preparation rules the fireground; a firefighter cardiac arrest is no different. 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. Take your regular cardio-pulmonary resuscitation (CPR) mannequin and add turnout gear and SCBA. Practice taking off turnout gear and SCBA while wearing firefighting gloves, and then transition over to EMS gloves. If you have an old set of turnout gear, try to find different ways to remove it (trauma shears, pocketknife, other commercial devices). Drill your ALS and BLS cardiac arrest skills (venous access, airway management, CPR, and so on). As much as basic skill execution on the fireground is the key to success, basic EMS skills will be the key to successful outcomes when a firefighter is down. Even with the uniqueness of the firefighter as a patient, good CPR still works. It just is not as straightforward as it was when dealing with a civilian.
Firefighters are more susceptible to cardiovascular events than the average person because of their work environments and exertion levels. Additionally, firefighters operate in unique environments, situations, and outer ensemble. The fire service is in the midst of a cultural change where fitness, health and wellness are taking a front seat. However, until we see a reduction of cardiac related LODDs, fire and EMS departments across the country need to be prepared to deal with a firefighter cardiac arrest. Will you be ready?
Photo found on Wikimedia Commons courtesy of Tim Evanson
Brown J, Stickford J. Physiological stress associated with structural firefighting observed in professional firefighters. Accessed March 24, 2014, from www.indiana.edu/~firefit/pdf/Final%20Report.pdf
Colwell C. Firefighters have narrower than normal arteries study finds. 2009, Mar 13. Accessed March 24, 2014 from http://consumer.healthday.com/cardiovascular-and-health-information-20/heart-stroke-related-stroke-353/firefighters-have-narrower-than-normal-arteries-study-finds-625032.html.
Centers for Disease Control. Heart disease facts. 2013, Aug 28. Accessed March 24, 2014 from www.cdc.gov/heartdisease/facts.htm.
Robert C. Owens Sr. is a lieutenant and EMT-intermediate with the Henrico County (VA) Division of Fire. He began his fire service career with the Mechanicsville (VA) Volunteer Fire Department. He previously served as a career firefighter in Stafford County (VA). He is Virginia Department of Fire Programs-certified Instructor 2 and Fire Officer Level 4 and a mass-casualty incident management instructor for the Virginia Office of EMS. He has a bachelor’s degree in fire science from Columbia Southern University.