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Home , Asystole, Cardium

F2005 16

A Summary of a NIOSH fi re fi ghter fatality in ves ti ga tion August 24, 2005 Captain Suffers an Acute Aortic Dissection After Responding to Two Alarms and Subsequently Dies Due to – Pennsylvania

SUMMARY On January 21, 2004, a 35-year-old male vol- signifi cant risk to the safety and health of unteer Captain responded to two alarms: a mo- themselves or others. tor vehicle crash (MVC) with an injury, and a reported house fi re that turned out to be a false • Perform an annual physical performance alarm. Returning to the fi re station after the false (physical ability) evaluation to ensure alarm, he complained of not feeling well and went fi re fi ghters are physically capable of home. After being home about 15 minutes, he performing the essential job tasks of collapsed. The Captain was transported to the lo- structural fi re fi ghting. cal hospital and later fl own to a regional hospital for diagnostic testing. Despite having a cardiac • Phase in a mandatory wellness/fi tness pro- catheterization with coronary angiography, and a gram for fi re fi ghters to reduce risk factors chest computed tomography (CT) scan, his aortic for and improve dissection went undiagnosed. He was treated for cardiovascular capacity. bilateral pneumonia but his condition continued to deteriorate. Despite cardiopulmonary resus- • Ensure that fi re fi ghters are cleared for citation (CPR) and advanced life support (ALS), duty by a physician knowledgeable about the Captain was pronounced dead approximately the physical demands of fi re fi ghting, the 20 hours after his initial complaint. The autopsy personal protective equipment used by fi re revealed the cause of to be “hemoperi- fi ghters, and the various components of cardium” due to an “aortic rupture” and “aortic NFPA 1582, Standard on Comprehensive dissection.” Occupational Medicine Program for Fire Departments. It is unlikely the following recommendations could have prevented the Captain’s death. None- theless, the NIOSH investigators offer these The Fire Fighter Fatality Investigation and Preven tion recommendations to reduce the risk of on-the-job Program is conducted by the National Institute for attacks and sudden among Occu pa tion al Safety and Health (NIOSH). The purpose of fi re fi ghters. the program is to determine factors that cause or contrib ute to fi re fi ghter suffered in the line of duty. Identi fi ca tion of causal and contributing factors enable researchers and safety • Provide mandatory pre-placement and specialists to develop strategies for preventing future similar annual medical evaluations to ALL fi re incidents. The program does not seek to determine fault or place blame on fi re departments or individual fi re fi ghters. fi ghters consistent with NFPA 1582, To request additional copies of this report (specify the case Standard on Comprehensive Occupa- number shown in the shield above), other fatality investigation tional Medical Program for Fire Depart- reports, or further information, visit the Program Website at www.cdc.gov/niosh/fi rehome.html ments to determine their medical ability or call toll free 1-800-35-NIOSH to perform duties without presenting a 2005 Fatality Assessment and Control Evaluation Investigative Report #F2005-16

Captain Suffers an Acute Aortic Dissection After Responding to Two Alarms and Subsequently Dies Due to Hemopericardium – Pennsylvania

• Provide fi re fi ghters with medical clearance 1745 hours the Captain responded with other to wear self-contained breathing apparatus members of the FD to a MVC with injuries. (SCBA). During the response, the Captain ran equipment and conducted personnel accountability checks. Once the victim was removed from the vehicle, INTRODUCTION & METHODS the Captain returned to the station and resumed On January 22, 2004, a 35-year-old male Cap- the furnace work (1805 hours). At approximately tain died after suffering a dissection of his aortic 1954 hours the station was dispatched to a re- artery. On January 28, 2004, NIOSH contacted ported house fi re. The Captain drove the engine the affected fi re department (FD) to initiate the to the address and assumed incident command investigation. On June 13, 2005 an Occupational of outside operations. No fi re could be located Health Nurse Practitioner and a Public Health and the Captain cancelled incoming mutual aid intern from the NIOSH Fire Fighter Fatality companies. All units were released and the Investigation Team traveled to Pennsylvania to Captain returned to the station at approximately conduct an on-site investigation of the incident. 2048 hours. At the station, he complained of not feeling well and was relieved from completing During the investigation NIOSH personnel inter- the FD’s incident report. viewed the following people: The Captain drove his personal vehicle home. At • Fire Chief 2100 hours, the station received a call from the • Captain’s wife Captain’s wife stating that he was complaining of • Captain’s brother fullness in his throat when he suddenly collapsed. A paramedic and two other fi re fi ghters from the During the site visit NIOSH personnel reviewed station responded. Upon arrival, the Captain was the following documents: conscious, complaining of pain radiating from • FD policies and operating guidelines his neck to his groin. They administered basic • FD training records life support until the ambulance, staffed with two paramedics, arrived. The ambulance paramed- • FD annual report for 2004 ics found the Captain cyanotic, having diffi culty • Ambulance response report breathing, and complaining of throat pain radiat- • Hospital records ing to his groin that did not change with move- • Past medical records of the Captain ment. Vital signs were taken showing a pulse of from the primary care physician (PCP) 110 beats per minute (bpm), 32 respirations per • Autopsy results minute, and blood pressure 210/140 millimeters • Death certifi cate of mercury (mmHg). Paramedics administered ALS (oxygen applied via a non-rebreather mask and nitroglycerin administered) and applied an INVESTIGATIVE RESULTS electrocardiogram that indicated a normal sinus Incident. On January 21, 2004, at approximately rhythm (NSR). He was placed into the ambulance 1500 hours, the Captain was doing maintenance and transported to a local hospital’s emergency on the fi re station’s furnace. At approximately department (ED).

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Captain Suffers an Acute Aortic Dissection After Responding to Two Alarms and Subsequently Dies Due to Hemopericardium – Pennsylvania

The Captain arrived at the local ED at 2137 hours. was noted during the scan Initial impression in the ED was chest pain related and a widening upper mediastinum was noticed to (MI), otherwise known on the chest x-ray. The Captain was transferred as a heart attack. An electrocardiogram (EKG) to the medical and IV antibi- showed NSR with evidence of an old MI. Car- otics were administered. He remained alert and diac enzymes were normal. A chest x-ray was oriented until approximately 1645 hours. administered (lungs clear, no effusion, edema, or pneumonia, and with a normal heart size) but the At approximately 1645 hours the Captain sud- interpretation was hindered by the Captain’s body denly became ashen, lost consciousness, and mass (height 71 inches and weight 375 pounds). appeared to have a seizure. His heart rate was Vital signs at 2200 hours were pulse 91 bpm, 14 tachycardiac at 120 bpm. While waiting to get a respirations per minute, and a blood pressure of blood pressure reading, the Captain awoke briefl y 133/59 mmHg. At 1100 the Captain complained to complain of further abdominal pain. He again of more severe pain despite being administered lost consciousness and ALS measures were be- intravenous (IV) pain medications. At that time gun. He was intubated and a large caliber catheter vital signs were pulse 82 bpm, 24 respirations per was inserted into the femoral vein into which 3 minute, and blood pressure 118/52 mmHg. A re- liters of saline were administered under pressure. evaluation led the ED to suggest possible pulmo- No pulse or blood pressure could be identifi ed, nary embolism or aortic dissection. Recognizing and the Captain was given various ALS medica- that an emergent intervention was necessary, a tions that failed to convert his heart rhythm to transfer was arranged using helicopter transport one that would support life. The Captain’s heart to a larger regional hospital. The helicopter ar- rhythm degenerated into asystole (no heart beat) rived at the local hospital at 2335 hours, departed at which time resuscitation efforts ceased. He at 2350 hours, and arrived at the regional hospital was pronounced dead at 1730 hours on January at 2359 hours. 22, 2004.

At the regional hospital the Captain was imme- diately taken into the cardiac catheterization lab. Medical Findings. The death certifi cate, com- Coronary angiography was remarkable for the pleted by the attending physician, listed “bilateral lack of any signifi cant , a pneumonia” as the immediate cause of death. normal ejection fraction and a normal aortic root The autopsy was performed by a pathologist. caliber without evidence of dissection. Because Signifi cant fi ndings were as follows: the Captain was hypoxic on room air, he was subsequently admitted to the cardiac intensive • Hemopericardium with 575 milliliters (mL) care unit where a chest x-ray and CT scan were of primarily unclotted blood in performed. Once again, due to his body size, the • Rupture of the intra-pericardial portion of the quality of the study was reduced, but no evidence ascending thoracic of a pulmonary embolus or pulmonary effusion • Thoracoabdominal aortic dissection extending was found. However, posterior portions of both from the ascending aorta to the distal abdomi- lower lobes showed an opacifi cation that was nal aorta (4 cm above the iliac bifurcation) diagnosed as probable pneumonia. Also, a small • History of hypertension

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Captain Suffers an Acute Aortic Dissection After Responding to Two Alarms and Subsequently Dies Due to Hemopericardium – Pennsylvania

o , heart weighing 560 grams (normal < 400 grams) Training. The FD requires all new volunteer o Moderate cardiac left ventricular hyper- fi re fi ghter applicants to complete an application trophy and an interview with the chief. They are then voted on by the membership. They must attend • Minimal coronary artery disease (25% stenosis a fundamentals of fi re course at which they take of the left anterior descending and right coro- a physical agility test. This class is taught either nary arteries) during fi re week at the state fi re academy or at • No evidence of infection in his left or right any of the regional fi re schools. Once they have lung fi elds (pneumonia), although there were successfully passed this course new applicants bilateral serosanguinous pleural effusions are allowed to perform interior fi re attack. The (200 mL on the left, 150 mL on the right) Captain was a certifi ed state Fire Fighter I, EMT, o Morbid obesity, with a body mass index Hazmat, and Driver/Operator and had 18 years of 51.9 kilograms/meters2. A BMI over of fi re fi ghting experience. 30 kg/m2 is considered obese.1 Pre-placement Medical Evaluations. The FD does The fi re fi ghter had a history of hypertension not require a pre-placement medical evaluation. since at least 1998. His hypertension was under control by prescription medication with variable Periodic Medical Evaluations. The FD does compliance. His most recent blood pressure (Jan- not require periodic medical evaluations. Em- uary 9, 2004) was 150/100 mmHg. According to ployees injured at work are evaluated by and family and fi re department personnel, the Captain must be cleared for return to work by a township never exercised. He had expressed no signs or contracted physician. As described earlier, the symptoms of chest pain or any other discomfort Captain’s last medical examination occurred 12 to his wife, co-workers, or health care providers days before he died. prior to this incident. He had no family history of aortic dissection or aneurysm. Fitness/Wellness Programs. The fi re station has an aerobic fi tness program on site, but no strength training programs. Participation in fi tness train- DESCRIPTION OF THE FIRE ing is voluntary. No wellness/health maintenance DEPARTMENT programs (smoking cessation, weight control, At the time of the NIOSH investigation, the high blood pressure, diabetes, and cholesterol) FD was an all volunteer department consisting are offered by this department. The FD, how- of 34 fi re fi ghters. Its one fi re station served a ever, is considering implementing these health population of 5,000 in a geographic area of 10 maintenance programs. square miles.

In 2004, the FD responded to 400 calls: 26 fi res, DISCUSSION 199 rescue and medical calls, 8 hazardous condi- Aortic Dissection and the Pathophysiology of tion calls, 110 false alarm/good intent calls, 31 Sudden Death. Aortic dissection, a splitting of service calls, and 26 other calls and incidents. the aortic wall, is caused by a tear of the interior

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Captain Suffers an Acute Aortic Dissection After Responding to Two Alarms and Subsequently Dies Due to Hemopericardium – Pennsylvania lining of the aorta (intima).2-4 The initiating event Left . The Captain was is either a primary intimal tear with secondary found on autopsy to have had moderate left ven- dissection into the middle or muscular coat of tricular hypertrophy. Hypertrophy of the heart’s the artery (media) or a medial hemorrhage that left is a relatively common finding dissects into the intima. In this case, the autopsy among individuals with long-standing high blood confi rmed the presence of an intimal tear. The pressure (hypertension), a problem, pulsatile aortic fl ow then travels between the in- or cardiac (reduced blood supply to the ner and outer surfaces creating a false lumen.2-4 heart muscle). Cardiac hypertrophy is one form The Captain’s case was complicated by the retro- of hypertrophic (HCM). The di- grade fl ow back into the intra-pericardial portion agnosis of HCM, from the pathologist, was based of the ascending thoracic aorta. This allowed on his enlarged heart (560 grams; normal is < 400 blood to leak into the pericardium resulting in grams) and thickened left heart ventricles (1.6 . Cardiac tamponade applies centimeters; normal is 0.76-0.88 centimeters). pressure from the “outside” of the heart, decreas- ing cardiac output. Without intervention, cardiac Approximately one-half of HCM cases are tamponade due to aortic dissection typically leads transmitted genetically, typically in an autoso- to death. mal dominant trait without disease loci on at least eight different chromosomes. The cause of Hypertension is a predisposing factor for aortic HCM in the other patients is unknown. Because dissection. Uncontrolled hypertension can lead the Captain had siblings and children, medical to a weakening of the aortic wall. The weakened screening of relatives is warranted. wall and the increased pressure strain the aorta which, over time, can lead to a tear in the wall. 2,4 The Captain was diagnosed with hypertension RECOMMENDATIONS in 1998 and only had sporadic control since that It is unlikely the following recommendations time. could have prevented the Captain’s death. None- theless, the NIOSH investigators offer these The peak incidence of aortic dissection is in the recommendations to reduce the risk of on-the-job sixth and seventh decades of life. Men are more heart attacks and sudden cardiac arrest among affected than women by a ratio of 2:1. The pre- fi re fi ghters. sentations of aortic dissection and its variants are the consequences of intimal tear, dissecting Recommendation #1: Provide mandatory pre- hematoma, occlusion of involved arteries, and placement and annual medical evaluations to compression of adjacent tissues. Acute aortic ALL fi re fi ghters consistent with NFPA 1582, dissection typically presents with the sudden Standard on Comprehensive Occupational onset of pain, which is often described as very Medical Program for Fire Departments7 to severe chest pain that radiates to the back and determine their medical ability to perform du- is frequently associated with sweating (diapho- ties without presenting a signifi cant risk to the resis).2,4-6 Other symptoms include syncope, safety and health of themselves or others. dyspnea, and weakness.2

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Captain Suffers an Acute Aortic Dissection After Responding to Two Alarms and Subsequently Dies Due to Hemopericardium – Pennsylvania

Guidance regarding the content and frequency of ing.9 The IAFF and the IAFC joined in a com- pre-placement and periodic medical evaluations prehensive Fire Service Joint Labor Management and examinations for fi re fi ghters can be found in Wellness/Fitness Initiative to improve fi re fi ghter NFPA 1582 and in the report of the International quality of life and maintain physical and mental Association of Fire Fighters/International Asso- capabilities of fi re fi ghters. Ten fi re departments ciation of Fire Chiefs (IAFF/IAFC) wellness/fi t- across the United States joined this effort to pool ness initiative.8 The Department is not legally information about their physical fi tness programs required to follow any of these standards. and to create a practical fi re service program. They produced a manual and a video detailing The success of medical programs hinges on pro- elements of such a program.8 Wellness programs tecting the affected fi re fi ghter. The Department have been shown to be cost effective, typically by must 1) keep the medical records confi dential, 2) reducing the number of work-related injuries and provide alternate duty positions for fi re fi ghters lost work days.10,11 A similar cost savings has been in rehabilitation programs, and 3) provide perma- reported by the wellness program at the Phoenix nent alternate duty positions or other supportive Fire Department, where a 12-year commitment and/or compensated alternatives if the fi re fi ghter has resulted in a signifi cant reduction in disability is not medically qualifi ed to return to active fi re pension costs.12 fi ghting duties. In January 2004, the National Volunteer Fire Recommendation #2: Perform an annual Council and US Fire Administration published physical performance (physical ability) evalu- a comprehensive manual, Health and Wellness ation for ALL fi re fi ghters to ensure fi re fi ght- Guide for the Volunteer Fire Service.13 The guide ers are physically capable of performing the provides suggestions for program initiation and essential job tasks of structural fi re fi ghting features. This guide is useful for not only volun- teer fi re departments, but also small combination NFPA 1500, Standard on Fire Department Oc- fi re departments that could benefi t from some cupational Safety and Health Programs requires type of fi tness and wellness program. The FD fi re department members who engage in emer- should implement this recommendation to ensure gency operations to be annually evaluated and Coronary Artery Disease (CAD) risk factors are re- certifi ed by the fi re department as meeting the duced and cardiovascular capacity is increased. physical performance requirements identifi ed in paragraph 8-2.1.9 Recommendation #4: Ensure that fi re fi ghters are cleared for duty by a physician knowledge- Recommendation #3: Phase in a mandatory able about the physical demands of fi re fi ghting, wellness/fitness program for fire fighters to the personal protective equipment used by fi re reduce risk factors for cardiovascular disease fi ghters, and the various components of NFPA and improve cardiovascular capacity. 1582, Standard on Comprehensive Occupational Medicine Program for Fire Departments. NFPA 1500 requires a wellness program that pro- vides health promotion activities for preventing Physicians who provide input regarding medi- health problems and enhancing overall well-be- cal clearance for fi re fi ghting duties should be

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Captain Suffers an Acute Aortic Dissection After Responding to Two Alarms and Subsequently Dies Due to Hemopericardium – Pennsylvania knowledgeable about the physical demands of fi re proved State plans. Pennsylvania does not operate fi ghting and that fi re fi ghters frequently respond an OSHA-approved state plan, therefore, public to incidents in environments that are immediately sector employers are not required to comply with dangerous to life and health. They should also be OSHA standards. Nonetheless, we recommend familiar with a FF’s personal protective equip- following this standard to ensure fi re fi ghters are ment and the consensus guidelines published by medically cleared annually to wear SCBA. NFPA 1582, Standard on Comprehensive Oc- cupational Medicine Program for Fire Depart- REFERENCES ments. To ensure physicians are aware of these 1. National Heart Lung Blood Institute [2005]. guidelines, we recommend that the FD, or the Obesity education initiative. World Wide Web FF, provide the personal physicians with a copy (Accessed June 2005.) Available from http:// of NFPA 1582. www.nhlbisupport.com/bmi/bmicalc.htm

We also recommend the FD retain a “fi re depart- 2. Dzau VJ and Creager MA [2001]. Diseases of the ment physician” to review all medical clearances, aorta. In: Braunwald E, Fauci AS, Kasper DL, and not necessarily “rubber stamp” the opinions Hauser SL, Longo DL, Jameson JL, eds. Harri- th of specialists or other treating physicians regard- son’s principles of internal medicine. 15 Edition. New York: McGraw-Hill. pp. 1430-1433. ing return to work. This decision requires knowl- edge not only of the medical condition, but also 3. Rose AG and Lie JT [1997]. Dissecting an- of the fi re fi ghter’s job duties. Personal physicians eurysm of aorta. In: Bloom S, Lie JT, Silver may not be familiar with an employee’s job du- MD, eds. Diagnostic criteria for cardiovascular ties, or with guidance documents such as NFPA pathology. Philadelphia: Lippincott-Raven. pp. 1582. In addition, they may consider themselves 177-178. patient advocates and dismiss the potential public health impact of public safety offi cials who may 4. Glover JL [1989]. Miscellaneous vascular be suddenly incapacitated. Therefore, we recom- problems. In: Kelley WN, DeVita VT Jr., Du- mend that a “FD physician” who has the fi nal Pont HL, Harris ED Jr., Hazzard WR, Holmes decision regarding medical clearance review all EW, et al., eds. Textbook of internal medicine. Philadelphia: Lippincott. pp. 263-264. return-to-work clearances. 5. Fields HL and Martin JB [2001]. Pain: patho- Recommendation #5: Provide fi re fi ghters with physiology and management. In: Braunwald clearance to wear self-contained breathing ap- E, Fauci AS, Kasper DL, Hauser SL, Longo paratus (SCBA) as part of the Fire Department’s DL, Jameson JL, eds. Harrison’s principles medical evaluation program. of internal medicine. 15th Edition. New York: McGraw-Hill. p.62. OSHA’s Revised Respiratory Protection Standard requires employers to provide medical evalua- 6. Williams ES [1989]. Essential features of the tions and clearance for employees using respira- cardiac history and physical examination. In: tory protection.14 These clearance evaluations Kelley WN, DeVita VT Jr., DuPont HL, Harris ED Jr., Hazzard WR, Holmes EW, et al., eds. are required for private industry employees and Textbook of internal medicine. Philadelphia: public employees in states operating OSHA-ap- Lippincott. pp. 284-285.

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Captain Suffers an Acute Aortic Dissection After Responding to Two Alarms and Subsequently Dies Due to Hemopericardium – Pennsylvania

7. NFPA [2003]. Standard on comprehensive 11. Stein AD, Shakour SK, Zuidema RA [2000]. occupational medical program for fi re depart- Financial incentives, participation in employer ments. Quincy MA: National Fire Protection sponsored health promotion, and changes in Association. NFPA 1582. employee health and productivity: HealthPlus health quotient program. J Occup Environ Med 8. IAFF, IAFC. [2000]. The fi re service joint 42:1148-1155. labor management wellness/fi tness initiative. Washington, D.C.: International Association 12. City Auditor, City of Phoenix, AZ [1997]. Disabil- of Fire Fighters, International Association of ity retirement program evaluation. Jan 28, 1997. Fire Chiefs. 13. NVFC and USFA [2004]. Health and wellness 9. NFPA [1997]. Standard on fi re department oc- guide for the volunteer fi re service, Emmitsburg, cupational safety and health program. Quincy MD: Federal Emergency Management Agency; MA: National Fire Protection Association. USFA, Publication No. FA-267/January 2004. NFPA 1500. 14. 29 CFR 1910.134. Code of Federal Regula- 10. Maniscalco P, Lane R, Welke M, Mitchell J, tions. Occupational Safety and Health Admin- Husting L [1999]. Decreased rate of back in- istration: Respiratory Protection. Washington, juries through a wellness program for offshore DC: National Archives and Records Adminis- petroleum employees. J Occup Environ Med tration, Offi ce of the Federal Register. 41:813-820.

INVESTIGATOR INFORMATION This investigation was conducted by and the report written by:

J. Scott Jackson, RN, MSN Occupational Nurse Practitioner Meghan Butasek, Fire Fighter Association of Teachers of Preventative Medicine (ATPM) Intern

Mr. Jackson is with the NIOSH Fire Fighter Fatality Investigation and Prevention Program, Cardiovascu- lar Disease Component located in Cincinnati, Ohio. Ms. Butasek is a fi re fi ghter with the Charlottesville, Virginia, Fire Department and an ATPM intern as- signed to NIOSH for a 3-month rotation.

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