Cardiac Fatalities in Firefighters: An Analysis of the U.S. Fire Administration Database Soman Sen, MD, FACS, Tina Palmieri, MD, FACS, FCCM, David Greenhalgh, MD, FACS
Cardiac fatalities are the leading cause of death among all firefighters. Increasing age has been linked to increased cardiac fatalities in firefighters; however, circumstances surrounding in-line-of-duty cardiac firefighter deaths can also increase the risk of a cardiac death. The authors hypothesize that cardiac fatalities among firefighters will be related to the type of duty and level of physical exertion. The authors analyzed the Firefighter Fatalities and Statistics data collected by the U.S. Fire Administration (http://apps.usfa.fema.gov/ firefighter-fatalities/fatalityData/statistics) from January 2002 to December 2012. Data were analyzed for associations between age, firefighter classification, duty-type, and cause of fatal cardiac event. A total of 1153 firefighter fatalities occurred during the 10-year period reviewed. Of these, 47% were cardiac fatalities. Mean age was significantly higher in firefighters who suffered a cardiac fatality (52.0 ± 11.4 ± 40.8 ± 14.7 years; P < .05). Volunteer firefighters suffered significantly higher proportion of cardiac fatalities (62%; P < .05) followed by career firefighters (32%). Additionally, cardiac fatalities were the leading cause of death for volunteer firefighters (54%; P < .05). The highest proportion of cardiac fatalities occurred on-the-scene (29%; P < .05) followed by after-duty fatalities (25%). Stress and overexertion accounted for 98% of the cause of cardiac fatalities. Adjusting for rank and firefighter classification, age (odds ratio, 1.06; 95% confidence interval, 1.05–1.08) and stress or overexertion (odds ratio, 11.9; 95% confidence interval, 1.7–83.4) were independent predictors of a firefighter cardiac fatality. Both career and volunteer firefighters are at significantly higher risk of a fatal cardiac event as they age. These fatalities occur in a significant proportion on-the-scene. National efforts should be aimed at these highrisk populations to improve cardiovascular health. (J Burn Care Res 2016;37:191–195)
Cardiac firefighter fatalities are the leading cause of death among all U.S. firefighters.1 Age and cardiac fitness are associated with an increased risk of a cardiac fatality in firefighters.2 However, cardiac death in firefighters is also reported in younger firefighters. These deaths are attributable to lifestyle and metabolic factors.3,4 Additionally, firefighting may also increase the risk of cardiac death. Increased arterial stiffness and increased blood viscosity have been reported in firefighters after a few hours of onduty activity.5,6 The physiologic changes with arterial stiffness and decreased blood viscosity coupled with From the Department of Surgery, Division of Burn Surgery, University of California, Davis. Address correspondence to Soman Sen, MD, FACS, 2425 Stockton Blvd., Suite 718, Sacramento, California 95817. E-mail: soman. [email protected] Copyright © 2014 by the American Burn Association 1559-047X/2014 DOI: 10.1097/BCR.0000000000000225
compromised cardiovascular health may significantly increase the risk of a firefighter dying of a cardiac cause while on duty. In this report, we analyze the U.S. Fire Administration’s Fire Fatalities and Statistics data to determine associations between age, firefighter classification, duty-type, and cause of fatal firefighter cardiac events that occur while on duty. We hypothesize that cardiac fatalities among firefighters will be related to the type of duty and level of physical exertion. We also hypothesize that age will be a predictive factor for fatal cardiac events.
METHODS We analyzed the Firefighter Fatalities and Statistics data collected by the U.S. Fire Administration (http://apps.usfa.fema.gov/firefighter-fatalities/fatalityData/statistics) from January 2002 to December 2012. The data are collected from firefighter 191
Journal of Burn Care & Research May/June 2016
192 Sen, Palmieri, and Greenhalgh
fatalities from the U.S. 50 states, District of Columbia, Puerto Rico, the U.S. Virgin Islands, American Samoa, Northern Mariana Islands, and Guam. The fatality data have been collected annually for the past 36 years and encompass fatalities that occur in the following type of firefighters: career, volunteer, full-time public safety officers acting as firefighters, fire police, and local, state, and federal fire service personnel. A fatality that occurred while on on-duty is defined as any injury or illness that resulted in a fatal event. The definition of “on-duty” is the following: involved in operations at the scene of an emergency, whether it is a fire or nonfire incident; responding to or returning from an incident; performing other officially assigned duties such as training, maintenance, public education, inspection, investigations, court testimony, and fundraising; and being on-call, under orders, or on standby duty except at the individual’s home or place of business. The designation “other on duty” can refer to activities in the station, vehicle maintenance, physical fitness both supervised and nonsupervised, and equipment maintenance (National Fire Incident Reporting System Complete Reference Guide 2013 [www.nifrs.fema.gov]). A fatal event is also classified as on-duty if the firefighter becomes fatally injured or suffers a fatal injury at home while preparing to respond to an emergency or arriving at home or at another location shortly after being on-duty (www.usfa.fema.org). Action or mechanisms that lead to a fatality included the following: stress or overexertion, vehicle collision, struck by (object), caught or trapped, fall, and collapse (building or structure). These events are defined by the U.S. Fire Administration’s 2012 publication on firefighter fatalities (http://www.usfa. fema.gov/downloads/pdf/publications/ff_fat12.pdf). Stress or overexertion is defined as a cause of death from strenuous physical work that is cardiac, cerebrovascular, and other events such as extreme thermal exposure. We analyzed the data for associations between age, firefighter classification, duty-type, and cause of the fatal cardiac event. R statistical package (www.rproject.org) was used to analyze the data. Continuous variable comparisons between two groups were performed using the 2-sample student’s t-test for continuous parametric data. Analysis of variance with Tukey’s honest significant difference post hoc analysis was performed for comparisons between three or more groups for continuous data. The chisquare test was used to assess association between discrete categorical variables. Multivariate logistic regression model was used to assess for predictors
of a fatal cardiac event. Predictor variables for the analysis included age and cause of the fatal events. Models were adjusted for rank and classification of the firefighters.
RESULTS From January 2002 to December 2012, a total of 1153 firefighter fatalities were reported. Mean age of the firefighters was 46 ± 14 years. Volunteer (53%) and career (37%) firefighters suffered the highest number of fatalities. Most of the fatalities occurred while responding to emergencies (61%) and most Table 1. Firefighter fatalities from 2002 to 2012 Rank Firefighter Captain Lieutenant Fire chief Pilot Chief Other Classification Volunteer Career Wildland contract Wildland full-time Paid-on call Wildland part-time Other Cause Cardiac Trauma Asphyxiation Burns CVA Other Activity or mechanism Stress or overexertion Vehicle collision Struck by Caught or trapped Fall Collapse Other Duty-type On-scene fire Other on duty Responding After Training On-scene nonfire Other CVA, cerebrovascular accident.
Fatalities
Frequency (%)
466 100 87 69 23 20 388
40 9 8 6 2 2 34
614 429 32 27 19 14 18
53 37 3 2 2 1 2
538 339 92 45 42 97
47 29 8 4 4 8
583 184 123 101 51 37 74
51 16 11 9 4 3 6
348 208 192 159 126 94 26
30 18 17 14 11 8 2
Journal of Burn Care & Research Volume 37, Number 3
Sen, Palmieri, and Greenhalgh 193
Table 2. Mean age of firefighter fatalities
Table 4. Firefighter fatalities by classification
Cause of Fatality Asphyxiation Burns CVA Crushed Drowning Electrocution Cardiac Heat exhaustion Trauma Violence
Age 37.5 ± 10.6 36.4 ± 12.5 51.7 ± 11.9 40.92 ± 10.2 40.3 ± 2.1 46.2 ± 11.1 52.04 ± 11.4* 34.4 ± 15.1 40 ± 16 38.9 ± 14.2
*P < .05 vs asphyxiation, burns, crushed, drowning, electrocution, heat exhaustion, trauma, and violence. All mean values are mean ± standard deviation.
occurred while on the scene of a fire or other event (38%). Cardiac fatalities (47%) were the leading cause of fatalities, followed by trauma (29%). The causes of all other on-duty fatalities were very low including deaths from burns (4%; Table 1). Firefighters who suffered a cardiac fatality were significantly older than firefighters who suffered all other fatalities (52 ± 11.4 vs 40.8 ± 14.7 years; Table 2). Of the 538 cardiac fatalities, volunteer firefighters suffered a significantly higher proportion of cardiac fatalities (62%) followed by career firefighters (32%). In addition, volunteer firefighters were the oldest group of firefighters and cardiac fatalities were the major cause of all volunteer firefighter fatalities (54%; Tables 3 and 4). Most cardiac fatalities occurred either on the scene of a fire or other nonfire event (29%) followed by fatalities that occurred after arriving home or to another location from a duty call (25%). Stress or overexertion was the most predominant activity that led to a fatal cardiac event (Tables 5 and 6). In order to determine risk factors for a cardiac fatality, multivariate logistic regression analysis was used to determine if age, activity or mechanism, and location of duty were independent predictors of a Table 3. Mean age of firefighter classifications Classification Career Industrial Paid-on-call Paid part-time Volunteer Wildland contract Wildland full-time Wildland part-time
Age 43.5 ± 10.7 48 ± 7 44.5 ± 15.6 43.1 ± 16.5 48.7 ± 15.9* 44.8 ± 15.4 38.9 ± 11.6 27.9 ± 9.9
*P < .05 vs career, wildland contract, wildland full-time, wildland parttime. All mean values are mena ± standard deviation.
Classification Career Industrial Paid-on-call Part-time Volunteer Wildland (contract) Wildland (full-time) Wildland (part-time)
Other
Cardiac
257 1 6 5 280 30 21 13
171 2 13 8 334* 2 6 1
Other – all other fatal causes, cardiac-fatal cardiac event. *P < .05.
cardiac event. All models were adjusted for rank and firefighter classification. The analysis indicates that age (odds ratio, 1.06) and stress or overexertion (odds ratio, 11.6) were both independent predictors of a fatal cardiac event (Table 7). Location of duty was not a statistically significant predictor.
DISCUSSION Of more than 1 million firefighters in the United States and surrounding commonwealths and territories, 49% are more than the age of 40.7 Coupling this with the growing evidence of firefighter fitness, weight, lifestyles, and on-duty activities contributing to the increased risk of cardiac death indicates that on-duty cardiac death rates are significant area of concern.8 In fact, a comparison of U.S. public cardiac death frequencies indicates that on-duty fire cardiac death is more frequent than the general population’s cardiac death. The National Vital Statistics Report for 2011 reports that cardiac deaths accounted for 24% of all deaths in the United States.9 This is far lower than 47% on-duty cardiac deaths reported in the Firefighter Fatalities and Statistics data collected by the U.S. Fire Administration. The cause of firefighter cardiac death is multifactorial. Firefighter fitness, especially with age, has been linked to an increased risk of cardiac death.10,11 Table 5. Duty location of firefighter fatalities Duty Location After On-scene fire and nonfire Other – on duty Responding Returning Training
Other
Cardiac
22 286 102 132 12 58
137 156* 106 60 12 67
Other – all other fatal causes, cardiac-fatal cardiac event. *P < .05.
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194 Sen, Palmieri, and Greenhalgh
Table 6. Activity or mechanism of firefighter fatalities Activity or Mechanism Assault Caught or trapped Collapse Exposure Fall Lost Other Out of air Stress or overexertion Struck by Unknown Vehicle collision
Other
Cardiac
4 101 37 11 51 10 31 2 55 123 4 184
0 0 0 2 0 0 3 2 527* 0 4 0
Other – all other fatal causes, cardiac-fatal cardiac event. *P < .05.
Additionally, firefighter physiology during on-scene activity may also significantly contribute to cardiac death rates. Firefighters on-scene are reported to have increased arterial stiffness, increase blood viscosity, and increased serum coagulation factors after a few hours of firefighting.5,6,12 These findings are in-line with our analysis that indicates that 29% of cardiac fatalities happen on-scene and another 25% happen after returning from a scene or duty activity. Additionally, our data indicate that stress and overexertion is the most impactful risk factor for cardiac death. This is similar to previous reports indicating that firefighters in high stress situations were at increased risk of cardiac death.1,13 Volunteer firefighter account for 69% of all firefighters in the United States and are responsible for protecting more than one-third of the U.S. population.7 Volunteer firefighters also suffer the highest frequency of on-duty cardiac death of any classification of firefighter. In addition to the added risks from firefighting, volunteer firefighters are on average older and suffer from metabolic and fitness issues that contribute to cardiac death risks. A report of volunteer firefighter body mass index (BMI) indicates that about 60% of volunteer firefighters have a BMI over 30 kg/m2.14 Additionally, 30 to 60% of career firefighters are also reported to have BMI greater than 30 kg/m2.15 The increased BMI in Table 7. Multivariate logistic regression analysis for independent predictors of a fatal cardiac event Variable
OR
95% CI
Stress or overexertion Age
11.9 1.06
1.7–83.4 1.05–1.08
OR, odds ratio; CI, confidence interval.
volunteer firefighter may increase the risk of metabolic syndrome, which is inversely correlated to cardiorespiratory fitness in firefighters.4 Other differences in requirements, training, and health insurance may account for some of the differences in cardiac death between volunteer and career firefighters. According to VolunteerFD.org (www. volunteerfd.org), the requirements and screening for volunteer firefighters vary by department. The particular department does the training, and subsequent frequency of drills and physical training is also done by the particular department. According to the Bureau of Labor statistics, career firefighters have to pass a written and physical test and requirements for becoming a firefighter is under city, county, or state jurisdiction. Perhaps the most significant difference is that volunteer firefighters are not paid or may be paid after providing a time of service. As a consequence, most of them do not get health insurance coverage and must find other ways to provide health insurance. Establishing uniforms standards for firefighter screening, fitness training, and health insurance for volunteer firefighters may help reduce the high incidence of cardiac death. Firefighters put themselves at risk of injury and dying while on-duty. Advancements in training, technique, and equipment have had a significant impact on firefighter safety.16–18 However, cardiac death remains the single most common cause of death among all firefighters. Improvements in education, uniform fitness guidelines, and annual evaluation of cardiovascular fitness can lead to reduced risk of on-duty cardiac death for all firefighters.19 Research efforts should be directed toward developing effective interventions that will lead to improved cardiovascular health and reduced risk of on-duty death.
CONCLUSION Cardiac death is the leading cause of on-duty firefighter death in the United States during the past 10 years. The majority of the deaths occur either on-the-scene or after responding to a duty-call. Older firefighters and volunteer firefighters are at increased risk of cardiac death. Stress and overexertion is a significant risk factor for an on-duty cardiac death. National efforts should be directed toward implementing guidelines to improve firefighter cardiovascular health. REFERENCES 1. Kahn SA, Woods J, Rae L. Line of duty firefighter fatalities: an evolving trend over time. J Burn Care Res 2015;36(1):218–24.
Journal of Burn Care & Research Volume 37, Number 3
2. Kales SN, Soteriades ES, Christoudias SG, Christiani DC. Firefighters and on-duty deaths from coronary heart disease: a case control study. Environ Health 2003;2(1):14. 3. Yang J, Teehan D, Farioli A, Baur DM, Smith D, Kales SN. Sudden cardiac death among firefighters
Cardiac fatalities are the leading cause of death among all firefighters. Increasing age has been linked to increased cardiac fatalities in firefighters; however, circumstances surrounding in-line-of-duty cardiac firefighter deaths can also increase the risk of a cardiac death. The authors hypothesize that cardiac fatalities among firefighters will be related to the type of duty and level of physical exertion. The authors analyzed the Firefighter Fatalities and Statistics data collected by the U.S. Fire Administration (http://apps.usfa.fema.gov/ firefighter-fatalities/fatalityData/statistics) from January 2002 to December 2012. Data were analyzed for associations between age, firefighter classification, duty-type, and cause of fatal cardiac event. A total of 1153 firefighter fatalities occurred during the 10-year period reviewed. Of these, 47% were cardiac fatalities. Mean age was significantly higher in firefighters who suffered a cardiac fatality (52.0 ± 11.4 ± 40.8 ± 14.7 years; P < .05). Volunteer firefighters suffered significantly higher proportion of cardiac fatalities (62%; P < .05) followed by career firefighters (32%). Additionally, cardiac fatalities were the leading cause of death for volunteer firefighters (54%; P < .05). The highest proportion of cardiac fatalities occurred on-the-scene (29%; P < .05) followed by after-duty fatalities (25%). Stress and overexertion accounted for 98% of the cause of cardiac fatalities. Adjusting for rank and firefighter classification, age (odds ratio, 1.06; 95% confidence interval, 1.05–1.08) and stress or overexertion (odds ratio, 11.9; 95% confidence interval, 1.7–83.4) were independent predictors of a firefighter cardiac fatality. Both career and volunteer firefighters are at significantly higher risk of a fatal cardiac event as they age. These fatalities occur in a significant proportion on-the-scene. National efforts should be aimed at these highrisk populations to improve cardiovascular health. (J Burn Care Res 2016;37:191–195)
Cardiac firefighter fatalities are the leading cause of death among all U.S. firefighters.1 Age and cardiac fitness are associated with an increased risk of a cardiac fatality in firefighters.2 However, cardiac death in firefighters is also reported in younger firefighters. These deaths are attributable to lifestyle and metabolic factors.3,4 Additionally, firefighting may also increase the risk of cardiac death. Increased arterial stiffness and increased blood viscosity have been reported in firefighters after a few hours of onduty activity.5,6 The physiologic changes with arterial stiffness and decreased blood viscosity coupled with From the Department of Surgery, Division of Burn Surgery, University of California, Davis. Address correspondence to Soman Sen, MD, FACS, 2425 Stockton Blvd., Suite 718, Sacramento, California 95817. E-mail: soman. [email protected] Copyright © 2014 by the American Burn Association 1559-047X/2014 DOI: 10.1097/BCR.0000000000000225
compromised cardiovascular health may significantly increase the risk of a firefighter dying of a cardiac cause while on duty. In this report, we analyze the U.S. Fire Administration’s Fire Fatalities and Statistics data to determine associations between age, firefighter classification, duty-type, and cause of fatal firefighter cardiac events that occur while on duty. We hypothesize that cardiac fatalities among firefighters will be related to the type of duty and level of physical exertion. We also hypothesize that age will be a predictive factor for fatal cardiac events.
METHODS We analyzed the Firefighter Fatalities and Statistics data collected by the U.S. Fire Administration (http://apps.usfa.fema.gov/firefighter-fatalities/fatalityData/statistics) from January 2002 to December 2012. The data are collected from firefighter 191
Journal of Burn Care & Research May/June 2016
192 Sen, Palmieri, and Greenhalgh
fatalities from the U.S. 50 states, District of Columbia, Puerto Rico, the U.S. Virgin Islands, American Samoa, Northern Mariana Islands, and Guam. The fatality data have been collected annually for the past 36 years and encompass fatalities that occur in the following type of firefighters: career, volunteer, full-time public safety officers acting as firefighters, fire police, and local, state, and federal fire service personnel. A fatality that occurred while on on-duty is defined as any injury or illness that resulted in a fatal event. The definition of “on-duty” is the following: involved in operations at the scene of an emergency, whether it is a fire or nonfire incident; responding to or returning from an incident; performing other officially assigned duties such as training, maintenance, public education, inspection, investigations, court testimony, and fundraising; and being on-call, under orders, or on standby duty except at the individual’s home or place of business. The designation “other on duty” can refer to activities in the station, vehicle maintenance, physical fitness both supervised and nonsupervised, and equipment maintenance (National Fire Incident Reporting System Complete Reference Guide 2013 [www.nifrs.fema.gov]). A fatal event is also classified as on-duty if the firefighter becomes fatally injured or suffers a fatal injury at home while preparing to respond to an emergency or arriving at home or at another location shortly after being on-duty (www.usfa.fema.org). Action or mechanisms that lead to a fatality included the following: stress or overexertion, vehicle collision, struck by (object), caught or trapped, fall, and collapse (building or structure). These events are defined by the U.S. Fire Administration’s 2012 publication on firefighter fatalities (http://www.usfa. fema.gov/downloads/pdf/publications/ff_fat12.pdf). Stress or overexertion is defined as a cause of death from strenuous physical work that is cardiac, cerebrovascular, and other events such as extreme thermal exposure. We analyzed the data for associations between age, firefighter classification, duty-type, and cause of the fatal cardiac event. R statistical package (www.rproject.org) was used to analyze the data. Continuous variable comparisons between two groups were performed using the 2-sample student’s t-test for continuous parametric data. Analysis of variance with Tukey’s honest significant difference post hoc analysis was performed for comparisons between three or more groups for continuous data. The chisquare test was used to assess association between discrete categorical variables. Multivariate logistic regression model was used to assess for predictors
of a fatal cardiac event. Predictor variables for the analysis included age and cause of the fatal events. Models were adjusted for rank and classification of the firefighters.
RESULTS From January 2002 to December 2012, a total of 1153 firefighter fatalities were reported. Mean age of the firefighters was 46 ± 14 years. Volunteer (53%) and career (37%) firefighters suffered the highest number of fatalities. Most of the fatalities occurred while responding to emergencies (61%) and most Table 1. Firefighter fatalities from 2002 to 2012 Rank Firefighter Captain Lieutenant Fire chief Pilot Chief Other Classification Volunteer Career Wildland contract Wildland full-time Paid-on call Wildland part-time Other Cause Cardiac Trauma Asphyxiation Burns CVA Other Activity or mechanism Stress or overexertion Vehicle collision Struck by Caught or trapped Fall Collapse Other Duty-type On-scene fire Other on duty Responding After Training On-scene nonfire Other CVA, cerebrovascular accident.
Fatalities
Frequency (%)
466 100 87 69 23 20 388
40 9 8 6 2 2 34
614 429 32 27 19 14 18
53 37 3 2 2 1 2
538 339 92 45 42 97
47 29 8 4 4 8
583 184 123 101 51 37 74
51 16 11 9 4 3 6
348 208 192 159 126 94 26
30 18 17 14 11 8 2
Journal of Burn Care & Research Volume 37, Number 3
Sen, Palmieri, and Greenhalgh 193
Table 2. Mean age of firefighter fatalities
Table 4. Firefighter fatalities by classification
Cause of Fatality Asphyxiation Burns CVA Crushed Drowning Electrocution Cardiac Heat exhaustion Trauma Violence
Age 37.5 ± 10.6 36.4 ± 12.5 51.7 ± 11.9 40.92 ± 10.2 40.3 ± 2.1 46.2 ± 11.1 52.04 ± 11.4* 34.4 ± 15.1 40 ± 16 38.9 ± 14.2
*P < .05 vs asphyxiation, burns, crushed, drowning, electrocution, heat exhaustion, trauma, and violence. All mean values are mean ± standard deviation.
occurred while on the scene of a fire or other event (38%). Cardiac fatalities (47%) were the leading cause of fatalities, followed by trauma (29%). The causes of all other on-duty fatalities were very low including deaths from burns (4%; Table 1). Firefighters who suffered a cardiac fatality were significantly older than firefighters who suffered all other fatalities (52 ± 11.4 vs 40.8 ± 14.7 years; Table 2). Of the 538 cardiac fatalities, volunteer firefighters suffered a significantly higher proportion of cardiac fatalities (62%) followed by career firefighters (32%). In addition, volunteer firefighters were the oldest group of firefighters and cardiac fatalities were the major cause of all volunteer firefighter fatalities (54%; Tables 3 and 4). Most cardiac fatalities occurred either on the scene of a fire or other nonfire event (29%) followed by fatalities that occurred after arriving home or to another location from a duty call (25%). Stress or overexertion was the most predominant activity that led to a fatal cardiac event (Tables 5 and 6). In order to determine risk factors for a cardiac fatality, multivariate logistic regression analysis was used to determine if age, activity or mechanism, and location of duty were independent predictors of a Table 3. Mean age of firefighter classifications Classification Career Industrial Paid-on-call Paid part-time Volunteer Wildland contract Wildland full-time Wildland part-time
Age 43.5 ± 10.7 48 ± 7 44.5 ± 15.6 43.1 ± 16.5 48.7 ± 15.9* 44.8 ± 15.4 38.9 ± 11.6 27.9 ± 9.9
*P < .05 vs career, wildland contract, wildland full-time, wildland parttime. All mean values are mena ± standard deviation.
Classification Career Industrial Paid-on-call Part-time Volunteer Wildland (contract) Wildland (full-time) Wildland (part-time)
Other
Cardiac
257 1 6 5 280 30 21 13
171 2 13 8 334* 2 6 1
Other – all other fatal causes, cardiac-fatal cardiac event. *P < .05.
cardiac event. All models were adjusted for rank and firefighter classification. The analysis indicates that age (odds ratio, 1.06) and stress or overexertion (odds ratio, 11.6) were both independent predictors of a fatal cardiac event (Table 7). Location of duty was not a statistically significant predictor.
DISCUSSION Of more than 1 million firefighters in the United States and surrounding commonwealths and territories, 49% are more than the age of 40.7 Coupling this with the growing evidence of firefighter fitness, weight, lifestyles, and on-duty activities contributing to the increased risk of cardiac death indicates that on-duty cardiac death rates are significant area of concern.8 In fact, a comparison of U.S. public cardiac death frequencies indicates that on-duty fire cardiac death is more frequent than the general population’s cardiac death. The National Vital Statistics Report for 2011 reports that cardiac deaths accounted for 24% of all deaths in the United States.9 This is far lower than 47% on-duty cardiac deaths reported in the Firefighter Fatalities and Statistics data collected by the U.S. Fire Administration. The cause of firefighter cardiac death is multifactorial. Firefighter fitness, especially with age, has been linked to an increased risk of cardiac death.10,11 Table 5. Duty location of firefighter fatalities Duty Location After On-scene fire and nonfire Other – on duty Responding Returning Training
Other
Cardiac
22 286 102 132 12 58
137 156* 106 60 12 67
Other – all other fatal causes, cardiac-fatal cardiac event. *P < .05.
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194 Sen, Palmieri, and Greenhalgh
Table 6. Activity or mechanism of firefighter fatalities Activity or Mechanism Assault Caught or trapped Collapse Exposure Fall Lost Other Out of air Stress or overexertion Struck by Unknown Vehicle collision
Other
Cardiac
4 101 37 11 51 10 31 2 55 123 4 184
0 0 0 2 0 0 3 2 527* 0 4 0
Other – all other fatal causes, cardiac-fatal cardiac event. *P < .05.
Additionally, firefighter physiology during on-scene activity may also significantly contribute to cardiac death rates. Firefighters on-scene are reported to have increased arterial stiffness, increase blood viscosity, and increased serum coagulation factors after a few hours of firefighting.5,6,12 These findings are in-line with our analysis that indicates that 29% of cardiac fatalities happen on-scene and another 25% happen after returning from a scene or duty activity. Additionally, our data indicate that stress and overexertion is the most impactful risk factor for cardiac death. This is similar to previous reports indicating that firefighters in high stress situations were at increased risk of cardiac death.1,13 Volunteer firefighter account for 69% of all firefighters in the United States and are responsible for protecting more than one-third of the U.S. population.7 Volunteer firefighters also suffer the highest frequency of on-duty cardiac death of any classification of firefighter. In addition to the added risks from firefighting, volunteer firefighters are on average older and suffer from metabolic and fitness issues that contribute to cardiac death risks. A report of volunteer firefighter body mass index (BMI) indicates that about 60% of volunteer firefighters have a BMI over 30 kg/m2.14 Additionally, 30 to 60% of career firefighters are also reported to have BMI greater than 30 kg/m2.15 The increased BMI in Table 7. Multivariate logistic regression analysis for independent predictors of a fatal cardiac event Variable
OR
95% CI
Stress or overexertion Age
11.9 1.06
1.7–83.4 1.05–1.08
OR, odds ratio; CI, confidence interval.
volunteer firefighter may increase the risk of metabolic syndrome, which is inversely correlated to cardiorespiratory fitness in firefighters.4 Other differences in requirements, training, and health insurance may account for some of the differences in cardiac death between volunteer and career firefighters. According to VolunteerFD.org (www. volunteerfd.org), the requirements and screening for volunteer firefighters vary by department. The particular department does the training, and subsequent frequency of drills and physical training is also done by the particular department. According to the Bureau of Labor statistics, career firefighters have to pass a written and physical test and requirements for becoming a firefighter is under city, county, or state jurisdiction. Perhaps the most significant difference is that volunteer firefighters are not paid or may be paid after providing a time of service. As a consequence, most of them do not get health insurance coverage and must find other ways to provide health insurance. Establishing uniforms standards for firefighter screening, fitness training, and health insurance for volunteer firefighters may help reduce the high incidence of cardiac death. Firefighters put themselves at risk of injury and dying while on-duty. Advancements in training, technique, and equipment have had a significant impact on firefighter safety.16–18 However, cardiac death remains the single most common cause of death among all firefighters. Improvements in education, uniform fitness guidelines, and annual evaluation of cardiovascular fitness can lead to reduced risk of on-duty cardiac death for all firefighters.19 Research efforts should be directed toward developing effective interventions that will lead to improved cardiovascular health and reduced risk of on-duty death.
CONCLUSION Cardiac death is the leading cause of on-duty firefighter death in the United States during the past 10 years. The majority of the deaths occur either on-the-scene or after responding to a duty-call. Older firefighters and volunteer firefighters are at increased risk of cardiac death. Stress and overexertion is a significant risk factor for an on-duty cardiac death. National efforts should be directed toward implementing guidelines to improve firefighter cardiovascular health. REFERENCES 1. Kahn SA, Woods J, Rae L. Line of duty firefighter fatalities: an evolving trend over time. J Burn Care Res 2015;36(1):218–24.
Journal of Burn Care & Research Volume 37, Number 3
2. Kales SN, Soteriades ES, Christoudias SG, Christiani DC. Firefighters and on-duty deaths from coronary heart disease: a case control study. Environ Health 2003;2(1):14. 3. Yang J, Teehan D, Farioli A, Baur DM, Smith D, Kales SN. Sudden cardiac death among firefighters
