Considering LODD Medical Information

The physical exam may be as important as the extra man on the truck

By Bill Carey

Originally published 17 August 2008

Also see: “Is It the Job or Your Body?” The intent is not to devalue or criticize the loss but to understand that there are differing methods of determining the data being presented. These differences may influence reported statistical data.

Maybe it’s not always the guy who is in poor shape. Maybe it is the combination of existing medical history as well as physical and mental stress. One constant safety for the fire service is the annual medical evaluation. In the District of Columbia this month, a routine department stress test identified a serious health condition in a 52 year old firefighter [1]. During the test, an electrocardiogram found a problem. The firefighter was transported to Washington Health Center and underwent quintuple bypass surgery and is now recovering. An annual physical fitness program with cardiac stress testing saved the life of a firefighter. Last week a number of line of duty death reports and a line of duty injury report were released to the fire service. The four NIOSH reports each attribute the cause of death to exertion, with the nature being sudden cardiac death [2]. Two of these deaths happened in 2006, the other two in 2007.

April 2006. A 57-year old volunteer Fire Chief was found dead the morning after a department training [3]. At 73 inches tall and weighing 248 pounds, he had a calculated body mass index of 32.7, considered obese [4]. He had two conflicting stress tests; the first in 2001 used persantine instead of exercise, to increase the heart rate. The second test in 2005 used exercise (treadmill test). This test was considered positive for exercise-induced schemia base on the EKG. With one test positive and another negative, the cardiologist (in 2005) concluded the exercise stress test was negative. Seven days prior to his death he passed a medical exam for a CDL. His “death was from a plaque rupture in the coronary circulation leading to coronary thrombosis, myocardial infarction and fatal arrhythmia [5].” In his department, annual medical exams are required. There is no health/wellness program nor is there a annual physical ability test.

August 2006. A 49 year old career firefighter/EMT participating in a voluntary department physical fitness program collapses while on a treadmill [6]. At 71 inches tall and 235 pounds, he is considered obese [7]. Diagnosed with high blood cholesterol, he was on a low fat diet and prescribed lipid lowering medication. Since 1997 he had exercise stress tests. No ischemic changes were noted in his history of tests. The autopsy revealed the firefighter had evidence of an old heart attack and an enlarged heart. He also had a common risk factor (atherosclerosis) for cardiac arrest. His department has annual medical evaluations, strength and aerobic equipment in quarters, available under voluntary use. There is no annual physical ability test.

January 2007. A 47 year old career lieutenant dies after working three consecutive 24-hour shifts, responding to 22 calls. After getting off duty form his tour he proceeded to exercise at a local gym, where he collapsed while on an exercise bicycle [8]. At 6 feet tall and weighing 272 pounds, his only risk factor was obesity [9]. He had a history of atrial fibrillation diagnosed in 1997 during a department medical exam. He was taken off-duty pending a cardiac evaluation. Both his echocardiogram and his exercise stress test were reported to be normal. He returned to duty being prescribed baby aspirin. In 2001 he experienced the same problem in another annual exam. He was off-duty for two weeks and then, after additional testing, prescribed various antiarrhythmic medications. In 2004 he had a surgical procedure to control persistent atrial fibrillation. He was last seen by a personal cardiologist in 2006 and cleared for duty. His department has annual medical evaluations with a exercise stress test for firefighters over 40 years of age. Exercise equipment in the station is used voluntarily and 1 ½-hours are given to members for exercise while on duty. The lieutenant was known to exercise regularly.

June 2007. A 53 year old career engineer dies while participating in a department physical fitness program. During the program the crew had also responded to three calls. At 73 inches tall and 232 pounds, the engineer is considered obese [10]; however using the skinfold test his BMI indicated not obese [11]. Since 1992 he had a history of hypertension and was prescribed medication. His blood pressure continued to stay elevated at department medical evaluations. His blood cholesterol had been elevated since 2000 and he was prescribed a low cholesterol diet, but no medication due to his HDL ratio. In 1990 he was diagnosed with intra-abdominal/aortic lymphoma and treated with surgery and chemotherapy. In 1999 he was diagnosed with testicular cancer and treated with surgery and radiation. In 2005 he underwent surgery for prostate cancer. His department has annual medical evaluations including treadmill fitness and treadmill stress tests. Chest x-rays are conducted every other year. Physical fitness is required, either aerobic or strength training, with equipment available in the station. There is no annual physical ability test.

The “Firefighter Fatalities In The United States – 2007” report states that deaths from exertion, stress and other medical issues are the largest in the Cause of Fatal Injury or Illness. 38 out of 40 deaths were categorized as “sudden cardiac deaths”. The number accounts for close to 40% of on-duty deaths annually. Post mortem information shows that 22 of the 38 had some form of pre-existing medical condition [12]. The NFPA, IAFF, IAFC and NVFC have been continually distributing information related to firefighter health and next week will see more during the National Firefighter Health Week beginning 18 August. As with any form of citing statistics, the actual data can be difficult to digest, especially if the synthesis begins broad and then develops detailed strata. For instance, in these four recently released reports a cursory light reading can lead us to believe that each of the fallen was of “that age” and had a poor health history. Only when we read in a detailed manner do we see that each one had medical condition disclosed while participating in a department medical evaluation. We can’t say that these men didn’t know about their conditions; on the contrary we learn that each one was systematically placed off-duty for additional testing and corrective measures and subsequently placed back on-duty following a department medical evaluation. There is also data that may be considered “conflicting” to the reader. Each of the four was considered obese by the National Heart, Lung and Blood Institute standards, yet in one there is mention of defining the body mass index by the skinfold test. Using the skinfold test is reportedly a better determining tool. In one of the four, there were no autopsy or toxicology tests performed. In another, the fallen was subjected to two different tests. Does this skew the statistics in deeper detail? Probably not, but it does cause us to consider ever more what it is that kills us, medically-speaking. We know there are people in Boston asking these questions [13]. And in a time when politicians and the general public have begun to scrutinize their fire departments [14], the physical exam may be as important as the extra man on the truck.

Definitions
Cause: The action, lack of action, or circumstances that resulted directly in the fatal injury.
Nature: The medical process by which death occurred and is often referred to as cause of death on d
eath certificates and in autopsy reports.
Persantine or Dipyridamole: A drug that inhibits thrombus formation when given chronically and causes vasodilation when given at high doses over short time.
Schemia or Ischemia: A restriction in blood supply, generally due to factors in the blood vessels, with resultant damage or dysfunction of tissue.

References
1. Stress Test Saves Firefighter. District of Columbia Fire and EMS Department, August 2008
2. NFPA 901, Uniform Coding for Fire Protection, 1981
3. Fire Chief Suffers Sudden Cardiac Death After Strenuous Training Drill – New York. NIOSH 2008
4. National Heart, Lung and Blood Institute 2005
5. Fire Chief Suffers Sudden Cardiac Death After Strenuous Training Drill – New York. NIOSH 2008
6. Firefighter-Emergency Medical Technician Suffers Sudden Cardiac Death During Physical Fitness Training – Nevada. NIOSH 2007
7. National Heart, Lung and Blood Institute 2005
8. After Working Three Consecutive 24-Hour Shifts and Fighting an Extensive Structure, a 47-Year Old Career LT Suffers Sudden Cardiac Death During Physical Fitness Training – California. NIOSH 2008
9. Ibid; National Heart, Lung and Blood Institute 2008
10. National Heart, Lung and Blood Institute 2005
11. Engineer Suffers Sudden Cardiac Death After Responding to Three Emergency Calls and Performing Physical Fitness Training – Arizona. NIOSH 2008
12. Firefighter Fatalities In The United States – 2007. NFPA, July 2008
13. Boston Commissioner Frustrated With Fatal Fire Probe Firehouse.com July 2008
14. Illinois Chief Won’t Change Exercise Policy Firehouse.com August 2008