Reducing Firefighter Injuries and LODDs

BY MIKE WATERS

With today’s science and technology, the fire service has learned more about every aspect of firefighting, especially its unique hazards, than our predecessors could ever have imagined. But despite this incredible amount of information, the number of those paying the ultimate price annually is not decreasing comparably. How can we be getting smarter and better equipped but yet still fall short of maintaining a healthy and capable workforce? The number-one killer of firefighters does not change year in and year out; yet, when a firefighter succumbs to a cardiac event, a large number of departmental and family members are always surprised and devastated by the loss. At what point does the responsibility for preventing injuries and line-of-duty deaths (LODDs) pass from the employer to the employee?

As my unit’s safety officer, it is my duty to identify preventable accidents and implement control mechanisms to prevent an accident, thus saving the department money from an injury and its related costs and, perhaps more importantly, saving the employee the pain and suffering and possibly work time lost from an injury. One of my goals from day one has been to correct “preventable accidents” whenever I see them and get our employees to focus on their own health and wellness.

Unfortunately in our occupation, many do not see the relevance or the consequence of maintaining the current culture or that great word that we like to throw around: “tradition.” We must change the traditions of what we do, on and off the job, if we want to significantly reduce cardiac-related deaths and disabilities in the fire service. I may be starting to annoy a few readers of this article. That’s good because that means the fire service still has a passion for what we do and where we came from. That same passion can be transformed into a driving force for us to make the needed changes from the inside out. I am not a medical doctor or a sports/physical training specialist; I am just a line company officer with some special emergency medical service and military experience. My goal is to break issues down to the simplest form and keep my explanations as simple and as easy to digest as possible.

Let’s begin with a look at a stark statistic from the past 10 years of reported data concerning firefighter fatalities (Table 1). With rare exceptions, such as 2001 and 2002, heart attacks are consistently the number-one cause of firefighter fatalities, generally followed by trauma. The fire industry has helped to reduce traumatic injuries through apparatus design, personal protective equipment improvements, and the establishment of training standards; these approaches have shown some success (Table 2).

table 1
table 2

But conversely, no big effort has been seen across the board toward health standards. Some departments offer their members incredible health and wellness programs and services, but still there has been only modest success. Why would you not want to better yourself and increase your long-term lifespan? Because the fire service is made up of Type A personalities who, until confronted with a life-altering event, feel immune and to some degree invulnerable to “those issues” even though we can recite the firefighter fatality statistics and know the increased risk we face. We will never be able to influence some people. This will always be true; the reason many wellness programs fail (or, more correctly, come up short, is that you can’t force people to do certain things).

Part of the issue is in the adoption of the National Fallen Firefighters Foundation (NFFF) 16 Life Safety Initiatives. Life Safety Initiative 1 says very clearly that the fire service needs to define and advocate the need for a cultural change within the fire service relating to safety, incorporating leadership, management, supervision, accountability, and personal responsibility. We are making headway on most of those components, but not personal responsibility.

So how do we make the proverbial horse drink the water? My practice has always been to give people as much information as possible so they can make an informed decision. Just as with the medical patients who refuse our care, it is our obligation to provide all the relevant information so that their choice is an “informed decision.” That is our obligation to our firefighters, too. If you can get someone to read or listen to all the information on their risks/decisions, they may eventually understand that they must focus on their health more. Perseverance is the key.

Hopefully, this will occur before a cardiac event. But all too often, our colleagues change their dietary/physical activity only after the fact. But the damage has already been done, and they are left with weakened heart tissue, leaving most with some permanent physical limitation and the need for continuous medication.

Every journey must start with a single step, so here is a simple roadmap to get all personnel on the right path to a long and rewarding career and an even more enjoyable retirement-one that is not burdened with health issues or restricted movement as a result of career injuries.

A ROADMAP FOR SUCCESS

Food as fuel. Nutrition is the most solid foundation for improving health, reducing injuries, and decreasing LODDs. Without good nutrition, you will never achieve your goals of ideal body composition and peak health. I have never liked the word “diet” because it has a connotation in our society and generally diets as people think of them don’t work. All too often, we see headlines about some new 30-day diet that will give you superpowers and is guaranteed to work. Diets are part of a multibillion-dollar industry even though they generally don’t work. But a large portion of the population wants a diet that is easy and minimally intrusive to their way of life, so they keep trying the latest and greatest diets. In the process, they buy books, meals, and online subscriptions, thus raising incredible revenues for the people selling their programs. The truth is that if you want change, you are going to have to change your normal routine, because your routine is what is getting you in trouble.

My preferred definition of diet is “habitual nourishment.” Modern foods are nothing like those our ancestors ate in terms of processing and the number of chemical ingredients that make up even the most basic items. We won’t know some of the long-term effects of such changes to our foods for decades. Although some effects are already starting to surface, most large food manufacturers dispute any connections.

Celiac disease, or gluten intolerance, is four times more prevalent than it was just a mere 60 years ago, according to a 2010 Mayo Clinic research study. Type 2 diabetes among young adults has risen substantially over the past decade, according to the American Diabetes Association. Attention deficit disorder also can be negatively influenced by some of the preservatives, artificial flavors, and dyes now common in most processed foods.

How do we avoid these things? Simply read labels. No one likes to take the time to read the labels on their spaghetti sauce jars or their fruit juice, but it makes a difference. An easy way to avoid ingredients that may harm your health is to pick the items with the fewest ingredients and to avoid those that list high fructose corn syrup (HFCS) as the first or second ingredient, since the ingredients are listed in order of quantity (by weight).

In addition to HFCS, sugar in all forms is causing health issues today. For example, consider dried fruit. If you placed a fresh piece of fruit in a food dehydrator for several hours and then ate it, you would taste the fruit’s sweetness and flavor with no additives or sweeteners. But if you look at commercially processed dried fruit, among the first ingredients listed are some type of sweetener and preservatives for longevity. Why do manufacturers add a sweetener to a product that is already naturally sweet? Simply because our taste buds’ sensitivity is declining, so manufacturers add flavors to reach both ends of the taste spectrum to make us enjoy the food (now even sweeter, saltier, and spicier than before) more. This excessive flavoring (or sweetening) of all foods is tricking our bodies and circumventing the body’s natural satiety limits, causing us to consume everything in excess. We have to stop the madness and reset our bodies and minds to restore the natural process and stop the unnatural health issues that result from these out-of-whack processes.

Free information is available on several dietary programs, including the paleo diet. (See The Paleo Solution by Robb Wolf, at www.robbwolf.com. Wolf is one of the foremost researchers on the paleo diet, which is based on the human diet of the paleolithic era.)

The Whole 9 group published It Starts with Food, available at www.whole9life.com. Several similar programs are available although they differ on some points of the paleo diet. As long as you understand the science behind the thinking, it might be the right program for you. The science behind the paleo diet is that the foods we eat regularly are not the same as those humans ate during the time of our paleolithic ancestors. This change in our diets, compounded by modern food processing, leads to the rapid increase in such medical woes as cancer, heart disease, diabetes, gastrointestinal issues, and other degenerative disorders.

The difference between the 15- or 30-day fad diet programs and the 30-day paleo challenge is that the fad diet programs require you to buy their programs; some even charge for the program’s required food. Most of these programs are finished after 15 or 30 days, unless you want to purchase more products. Some fad diets will show weight loss (usually water weight), but the losses are unsustainable. Shortly after the end of the program, your weight returns and can even increase because of the body’s natural defensive mechanisms. At that point, frustration usually sets in and dieters seek comfort in the foods they were missing out on and wait for the next diet that sounds promising to come along.

The 30-day paleo diet challenge, on the other hand, enables you to see some stark results in a short time. The 30 days serve as a benchmark for the skeptical. The diet is intended to be a way of life and doesn’t require special purchases or subscriptions. Some companies may sell supplements, but they are not meant to replace the core of the program, which is real food, prepared fresh. After the first 30 days on the paleo diet, my results were astounding. I am in my early 40s and had already been dealing with hypertension and high cholesterol. After the initial 30 days (and my diet was the only thing I changed in my lifestyle), my blood pressure was on the lower side of normal and my cholesterol looked like it did when I was much younger. My physician was impressed with the short-term positive changes I had experienced. I also received several unsolicited remarks that my mid-section was looking thinner.

Notice that I did not mention weight loss or body mass index (BMI) numbers. This is really key to the issue of overall health, because you should not be using them for your personal goals. The BMI scale as we all know it is completely inappropriate for the reason we use it. Today’s society, governments, and insurance companies want the convenience of using a person’s height and then plugging in the weight to get a targeted BMI score, but the underlying fallacy is that BMI was designed in the middle 1840s as an indicator of a culture’s general health. It was never meant to be an individual indicator. There are several other techniques far more accurate for fat measurement, but they are costly and require specialized equipment, making them impractical for widespread use. The reasons BMI is so widespread in use by the above groups are ease of application and there is almost no cost to assess. Therefore, even with its inherent flaws, BMI will continue to be used. In fact, some professional athletes who are in prime condition according to all visual indicators have BMIs that classify them as obese because the BMI doesn’t consider that muscle mass weighs more than fat.

Regarding weight loss, two people can both weigh 160 pounds, yet one may look very fit and the other very unfit, regardless of their respective heights. The reason for this is the uniqueness of each person. Do not use weight loss or the BMI as your benchmark for progress. Instead, focus on looking at yourself in the mirror before or right after you get out of the shower. Glance at yourself naked. You will either be happy or unhappy with what you see. That alone should be your motivator and benchmark for your goals. Once you address your nutrition and start seeing some positive changes in the mirror, your emotions will reinforce your actions and keep you going down the right path. If after that 30-day period you don’t see any significant changes, and you were diligently adhering to the eating guidelines, then you will be no worse off than when you started, and you aren’t out any money, either. Jason Seib, author of The Paleo Coach, does regular podcasts in which he ties in the nutrition, fitness, and emotional connection necessary for success.

Sleep. Sleep is completely natural and one of the body’s best ways to repair itself. It is also a widely overlooked and underused form of rest and recovery because of our busy lives and even more busy work shifts. According to the National Sleep Foundation, sleep deprivation can have direct effects on weight gain, irritability, heart disease, attention deficit hyperactivity disorder (ADHD), gastrointestinal issues, and countless other physical maladies. Although we can’t always control the sleep we get while on duty, we can maximize the rest we get prior to and after our tours to help alleviate some of the effects of the job. Most people don’t know how to get good sleep anymore in today’s electronic age.

Just as we wake up slowly and start getting ready for our day, so should we be preparing for bed. Begin about an hour before you plan on going to bed. Eliminate caffeinated beverages, and turn down some lights. Reduce your use of the computer and the television, and avoid any other distractions (e.g., cell phones and personal data assistants) during this time. Your sleep area should be free from all electronics or any other light sources that might get your attention during the night. The targeted amount of sleep should be a minimum of 7.5 hours per night of uninterrupted sleep. If you have to wake early for your commute to work, ensure you go to bed that much earlier in the evening prior. Although this section is short, do not underestimate its importance: Make every effort to maintain your sleep hours.

Many of us take the 30- to 45-minute “safety nap” after lunch to prep our bodies to function better during the night if we get multiple calls. Although safety naps have been proven to improve cognitive abilities during late-night sleep interruptions, they are not a replacement for the uninterrupted quality sleep that our bodies need for long-term health.

FITNESS AS A WHOLE

Most people think of fitness as getting a good workout in every day, but there is much more to it. The problem is that many people don’t know what to do or when to do it in terms of working out. As a result, a couple of crew members go to the free weights, and each tries to outpress the other, or another member goes and runs on the treadmill for an hour. Are these truly effective steps to take to improve our fitness levels?

The first step in fitness should be to determine your functional mobility and stability. Several movement screening programs are on the market; each varies slightly. I am a Functional Movement Screen™ (FMS) Level 1 certified member and am sold on the benefits of performing a basic movement screen on all individuals to determine their baseline mobility/stability. Why do you need to care about basic mobility? Because it is the foundation for every movement pattern we perform. A person with a decreased movement range or an impaired movement pattern is at higher risk for an injury.1

It all goes back to that “preventable injury” issue above. Younger firefighters may dispute this, saying they feel they are limber as can be and don’t have any issues. However, the generational changes that we are seeing populationwide are predominantly the result of our modern busy lives in which we spend more time sitting (e.g., driving, behind a desk, on the sofa at home) than earlier generations who spent much more time on their feet.

A screening usually will silence that person’s objections and even help him to identify some core issues he can and will want to work on. With a simple FMS, a screener can identify dysfunctional movement patterns or asymmetries and assign a corrective exercise regime to eliminate those dysfunctions. The screen is quickly performed, and the corrective exercises can be worked into a morning routine or a regular physical fitness session with minimal extra equipment or time. The screen also identifies exercises that the subject shouldn’t be performing until he clears the dysfunctional pattern. That really is the key in the prevention portion. Several studies conducted with the fire service demonstrate the efficacy of using the FMS for fire recruits2 as well as with the whole population of the Tucson (AZ) Fire Department personnel, who represent various ages and abilities.3

Once we address an individual’s ability to move without dysfunction, we need to provide some direction for building individual abilities. I am not a fan of cardio, specifically just getting on the treadmill for an hour and calling that a tough workout because you are sweaty. Several recent studies have cited the damaging effects of excessive cardio-type workouts.4 However, you should include cardio in your everyday life by walking more whenever possible. I like to hike frequently during the summer in full wildland gear because of the all-risk requirements of our job.

I prefer cross-training workouts, although not specifically CrossFit. CrossFit does have a place in the fire service. Many people claim that CrossFit injures people and shouldn’t be allowed on duty because the risk it poses to employees outweighs the benefits it provides. However, it is how the individual uses or abuses the CrossFit mentality that makes it beneficial or harmful. Yes, mentality, because Crossfit is a very competitive workout regime that pits each person against the timer.

The key to CrossFit is proper instruction and coaching. Unless you have that, you should not be pushing untrained individuals through a lot of the workouts (especially the ones that involve Olympic weightlifting skills) because the novice or untrained individual tends to sacrifice form for repetitions, which is how injuries often occur. I like the muscle confusion that cross-training provides, because if you are doing the same routine over and over, you will get bored and start skipping workouts. I don’t like standard aerobic cardio, but I really like anaerobic sprinting intervals. All you have to do is compare a typical marathon runner to a sprinter. Which body type do you want?

Along with fitness goes hydration. Our department over the past several years has seen a rise in rhabdomyolysis (rhabdo). Rhabdomyolysis is a serious syndrome caused by a direct or indirect muscle injury, the result of the breakdown of muscle fibers and release of their contents into the bloodstream. This can lead to complications such as kidney (renal) failure. Rhabdo seemed to hit our portion of the fire service out of nowhere, although the phenomenon was known in sports medicine for some time. A more consistent causal factor has been dehydration in the firefighters prior to their workouts, exertional periods on incidents, or insufficient rehydration after the event. We cannot overstress hydration in our occupation. As shown in a study by the Orange County (CA) Fire Authority, most firefighters are actually dehydrated prior to engaging in physical activity and thus are stressing their bodies, specifically their heart, even more on top of the high demands of the job.5

An essential part of fitness is knowing when not to work out. Many people will drag themselves, hangover and all, out of bed to get to the gym to feel productive for the day. We’ve all heard it from our buddy, “It was tough, but I did manage to get a good workout in, even though I was dragging my feet!” The problem with this mindset is that it is counterproductive if your body is in a deficient state.6 If you haven’t addressed the items above, nutrition and sleep, then you might as well take a rest day and let your body recover. The cumulative stress you will put it through when it isn’t ready will be completely counterproductive to any gain you think you are making.

Most people think they need to get a good burn every day to make progress. But if you are addressing your nutrition and sleep effectively, your body will make significant progress with only working out three times a week. This rest time allows full recovery and rebuilding for your body and allows for those optimal gains everyone wants to see from their efforts. Most coaches would agree that a good starting point to your fitness goals is to perform some type of physical assessment test. Once you score your results, you can move forward with deciding what your fitness goals are. A nice regime is to establish short- and long-term training goals (e.g., fitness goals for one, three, or six months), and then formulate a training plan along those guidelines based on your program. If you have addressed your functional movement patterns and are free of dysfunctional patterns or asymmetries, move forward with your targeted fitness goals.

•••

The top three priorities for all individuals should be nutrition, sleep, and fitness, in that order. Addressing these greatly diminishes your risk of injury, cardiac disease, and all other health issues. Everyone wants to be the exception to the rule and not one of the many statistics that reinforce that our chosen occupation is one of the deadliest industrywide. If more people started focusing on these three priorities, we can see a statistical decline in injuries and LODDs over the long term.

REFERENCES

1. Cook, G. (2010). Movement. Santa Cruz: On Target Publications.

2. Contreras, M. (2006). “How to Create and Sustain a Comprehensive Injury Prevention Program.” Orange County Fire Authority Firefighter Academy.

3. Peate WF, et al. (2007). “Core Strength: A New Model for Injury Prediction and Prevention.” Journal of Occupational Medicine and Toxicology, 2:3.

4. Skoluda, ND. (2011). “Elevated Hair Cortisol Concentrations in Endurance Athletes.” Psychoneuroendocrinology, 2012 May;37(5):611-7. doi: 10.1016/j.psyneuen.2011.09.001. Epub 2011 Sep 25.

5. Espinoza N. (2008). “Can We Stand the Heat?” Journal of Emergency Medical Services, 94-105.

6. Gleeson, M. (2007). “Immune Function in Sport and Exercise.” Journal of Applied Physiology, 103, 693-699.

MIKE WATERS is a captain with the CAL FIRE/Butte County (CA) Fire Department and is the CAL FIRE Butte unit safety officer.

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