2013 28 Death in the line of duty... Fire Fighter Fatality Investigation and Prevention Program

A summary of a NIOSH fire fighter fatality investigation April, 2014 Volunteer Lieutenant Suffers Sudden Cardiac Death at Fire Station While Doing Fitness Training – New York

Executive Summary On November 11, 2013, a 52-year-old volunteer Perform an annual physical performance (physi- Lieutenant (LT) attended the monthly business cal ability) evaluation. meeting at the fire department (FD). Following the meeting he went upstairs to use the exercise Phase in a mandatory comprehensive wellness room. After approximately 5 minutes, members and fitness program for fire fighters. heard a crashing sound, found the LT unrespon- sive and began cardiopulmonary resuscitation Introduction & Methods (CPR). The ambulance crew that was stationed On November 11, 2013, a 52-year-old volunteer at that FD began advanced cardiac life support LT suffered a sudden cardiac event while exercis- (ACLS). The LT was transported to the emergency ing at his fire station. NIOSH was notified of this department (ED) where ACLS continued. Despite fatality on November 13, 2013, by the U.S. Fire these efforts, the LT died. The death certificate and Administration. NIOSH contacted the affected FD autopsy report, both completed by the County’s on November 14, and again on November 27, 2013, Chief Medical Examiner, listed the cause of death to obtain additional information and to schedule the as “atherosclerotic and hypertensive cardiovascu- investigation. On December 11, 2013, a contractor lar disease.” The autopsy revealed severe coronary for the NIOSH Fire Fighter Fatality Investigation but no evidence of an acute throm- Team (the NIOSH investigator) conducted an on- bus or plaque hemorrhage. site investigation of the incident.

NIOSH offers the following recommendations to During the investigation, the NIOSH investigator reduce the risk of heart attacks and sudden cardiac interviewed the following people: arrest among fire fighters at this and other fire ●● Chief of the FD departments across the country. ●● Assistant Chief (serving as Chief at the time of the incident) who provided initial care Ensure that all fire fighters receive an annual ●● EMS personnel who provided treatment medical evaluation consistent with NFPA 1582, ●● Primary care physician Standard on Comprehensive Occupational Medi- cal Program for Fire Departments. The NIOSH investigator reviewed the following documents in preparing this report: Ensure fire fighters are cleared for duty by a ●● Ambulance pre-hospital care report physician knowledgeable about the physical ●● Death certificate demands of firefighting, the personal protective ●● Medical examiner’s report equipment used by fire fighters, and the various ●● Primary care physician medical records components of NFPA 1582. ●● FD medical records

A Summary of a NIOSH fire fighter fatality investigation Report #2013-28 Volunteer Lieutenant Suffers Sudden Cardiac Death at Fire Station While Doing Fitness Training – New York

The National Institute for Occupational Safety and Health (NIOSH), an institute within the Centers for Disease Control and Prevention (CDC), is the federal agency responsible for conducting research and making recommendations for the prevention of work-related injury and illness. In 1998, Congress appropriated funds to NIOSH to conduct a fire fighter initiative that resulted in the NIOSH “Fire Fighter Fatality Investigation and Prevention Program” which examines line-of-duty-deaths or on duty deaths of fire fighters to assist fire departments, fire fighters, the fire service and others to prevent similar fire fighter deaths in the future. The agency does not enforce compliance with State or Federal occupational safety and health standards and does not determine fault or assign blame. Participation of fire departments and individuals in NIOSH investigations is voluntary. Under its program, NIOSH investigators interview persons with knowledge of the incident who agree to be interviewed and review available records to develop a description of the conditions and circumstances leading to the death(s). Interviewees are not asked to sign sworn statements and interviews are not recorded. The agency’s reports do not name the victim, the fire department or those interviewed. The NIOSH report’s summary of the conditions and circumstances surrounding the fatality is intended to provide context to the agency’s recommendations and is not intended to be definitive for purposes of determining any claim or benefit. For further information, visit the program website at www.cdc.gov/niosh/fire or call toll free 1-800-CDC-INFO (1-800-232-4636).

Page 2 A Summary of a NIOSH fire fighter fatality investigation Report #2013-28 Volunteer Lieutenant Suffers Sudden Cardiac Death at Fire Station While Doing Fitness Training – New York Investigative Results Incident. On November 11, 2013, at 1900 hours, ACLS in progress. At 2136 hours a cardiac the FD held its monthly business meeting at the monitor replaced the AED and revealed pulseless fire station. The LT arrived at the fire station electrical activity. At approximately 2139 hours, before the meeting to work out in the station’s an endotracheal tube replaced the oropharyngeal upstairs exercise room. The LT used the exercise airway, with proper placement ensured by breath room on a regular basis, 4 to 6 times a week for sounds in both lung fields, an esophageal detection aerobic and weight training sessions lasting from devise, and capnography [Neumar et al. 2010]. At 30 to 60 minutes. Based on the log book, the LT 2144 hours, the ambulance arrived at the ED. was in the exercise room for 30 minutes (1815 and 1845 hours) but the extent and type of exercise he Upon arrival at the ED, the placement of did were unknown). The business meeting ended the endotracheal tube was confirmed with at approximately 2100 hours and the LT returned capnography. Another IV line was established, to the exercise room to complete his workout. cardiac medications were administered, and defibrillation was attempted. The LT did not regain Approximately 5 minutes after the LT went a viable heart rhythm during the resuscitation upstairs (2115 hours) members heard a loud crash. efforts and a cardiac ultrasound revealed no The Chief of the FD, a fire fighter (FF), and an cardiac wall motion. At 2223 hours, approximately emergency medical technician (EMT) stationed in 1 hour and 10 minutes after his collapse, the LT the fire station rushed upstairs and found the LT was pronounced dead and resuscitation efforts pulseless and unresponsive. The Chief and the FF were discontinued. began CPR while the EMT alerted her partner (a paramedic) and retrieved the automatic external Medical Findings. The death certificate defibrillator (AED) and other equipment from and autopsy, both completed by the Chief the ambulance stationed in the bay beneath the Medical Examiner, listed the cause of death as exercise room. “atherosclerotic and hypertensive .” Pertinent autopsy findings included The AED indicated that a shock was advised; it severe atherosclerosis with 99% calcified luminal was delivered with no change in the LT’s status. stenosis of the right coronary artery and 90% An oropharyngeal airway was inserted and the LT calcified luminal stenosis of the left anterior was provided with oxygen via a bag-valve mask. descending and left marginal artery. No coronary An intravenous line was placed and cardiac drugs or plaque hemorrhage was noted. were administered per ACLS protocols. The LT See Appendix A for more detailed autopsy was secured to a backboard and carried down a information. flight of stairs to the ambulance. In the back of the ambulance the LT was defibrillated a second time The LT had long-standing , diagnosed with no change in his clinical status. in 1999 and managed with antihypertensive medications by his primary care physician. His At 2136 hours the ambulance left the station pressure was well-controlled at his most en route to the hospital’s ED with CPR and recent measurement in August 2013 (132/90

Page 3 A Summary of a NIOSH fire fighter fatality investigation Report #2013-28 Volunteer Lieutenant Suffers Sudden Cardiac Death at Fire Station While Doing Fitness Training – New York Investigative Results (cont.) millimeters of mercury [mmHg]). The LT was a evaluation is conducted by the contract medical nonsmoker and a regular exerciser. He was cleared group, the FD requires a medical history, physical for unrestricted fire fighting duty during his last evaluation, urine dip test for glucose and ketones, FD medical evaluation in April 2011. At autopsy, and a hearing test. the LT was 70 inches tall and weighed about 187 pounds, giving him a body mass index of 26.8 Following an injury or illness, the member must kilograms per meter squared [CDC 2011]. present the FD with a PCP’s note regarding return to work. Description of the Fire Department Fitness/Wellness Programs. The FD has exercise The volunteer FD consists of 22 uniformed equipment at the fire station but does not provide a personnel serving a population of approximately 800 fitness or wellness program. residents in a geographic area of one square mile. Discussion Membership/Training. Candidates must have a valid driver’s license and be 18 years of age. Atherosclerotic Coronary Heart Disease. The After passing a background check, candidates most common risk factor for are voted on by the membership and become and sudden cardiac death is coronary heart probationary FD members for 90 days. During the disease (CHD), defined as the build-up of probationary period, provisional members receive atherosclerotic plaque in the weekly training by paid consultants. Additionally, [AHA 2012]. Risk factors for CHD include three FD officers train the provisional members for a non-modifiable factors (age older than 45, male minimum of 2 hours per month. Once the training gender, and family history of CHD) and six is complete, a “badge test” is administered modifiable factors (smoking, hypertension, high to ensure that new members are proficient in blood , obesity, physical inactivity, firefighting skills. Once the badge test is passed, and diabetes mellitus) [AHA 2012; National the FD Chief makes the final determination Cholesterol Education Program 2002]. The LT regarding membership. had four of these risk factors; he was a male over the age of 45 with a family history of CHD and Medical Evaluations/Medical Clearance. The diagnosed hypertension. FD requires pre-placement and periodic medical evaluations. These evaluations may be done by a The narrowing of the coronary arteries by member’s primary care provider (PCP) or they can atherosclerotic plaques occurs over many years, be conducted by the medical group under contract typically decades [Libby 2008]. However, the with the FD. If the evaluation is conducted by growth of these plaques probably occurs in a the member’s PCP, then the components of the nonlinear, often abrupt fashion [Shah 1997]. evaluation are determined by the PCP who then Most heart attacks occur when a vulnerable signs a note to the FD regarding the member’s plaque ruptures, causing a blood clot to form and clearance for fire fighting duties. If the medical occlude a coronary artery. Establishing a recent

Page 4 A Summary of a NIOSH fire fighter fatality investigation Report #2013-28 Volunteer Lieutenant Suffers Sudden Cardiac Death at Fire Station While Doing Fitness Training – New York Discussion (cont.) (acute) heart attack requires one or more of the condition could have been triggered by the following: characteristic electrocardiogram physical exertion of exercising in the fire station. (EKG) changes, elevated cardiac enzymes, or coronary artery . In this case, the LT Occupational Medical Standards for Structural did not have a heart rhythm to conduct an EKG Fire Fighters. To reduce the risk of sudden tracing, he died before cardiac enzymes would cardiac arrest or other incapacitating medical become elevated, and no thrombus was identified conditions among fire fighters, the National Fire at autopsy. However, heart attacks can occur Protection Association (NFPA) developed NFPA without evidence of a coronary thrombus [Davies 1582, Standard on Comprehensive Occupational 1992; Farb et al. 1995]. Medical Program for Fire Departments [NFPA 2013]. This voluntary industry standard provides Primary . Lethal ventricular (1) the components of a preplacement and annual can cause sudden cardiac deaths medical evaluation and (2) medical fitness for [Kelesidis and Travin 2012]. Risk factors for duty criteria. arrhythmias include cardiac disease, heart attack, sleep apnea, dietary supplements, smoking, NFPA 1582 recommends an exercise stress test alcohol, drug abuse, medications, diabetes, and with or without imaging be performed “when hyperthyroidism [AHA 2012; Mayo Clinic 2013]. clinically indicated by history or symptoms” The LT’s autopsy revealed severe coronary artery and refers the reader to its Appendix A [NFPA disease which increases the risk for primary 2013]. Items in Appendix A are not standard arrhythmia [AHA 2012; Mayo Clinic 2013]. requirements, but are provided for “informational purposes only.” Appendix A recommends using Strenuous Exertion and Sudden Cardiac Death. submaximal (85% of predicted maximal heart Epidemiologic studies in the general population rate) stress tests as a screening tool to evaluate have found that heavy physical exertion can a fire fighter’s aerobic capacity. trigger a heart attack and/or sudden cardiac death evaluation with a symptom-limiting stress test and [Tofler et al. 1992; Mittleman et al. 1993; Willich imaging studies should be used for fire fighters et al. 1993; Albert et al. 2000]. Epidemiologic with the following conditions: studies among fire fighters have shown that fire suppression, training, alarm response, or strenuous ●● abnormal screening submaximal tests physical activity on the job, in the preceding 12 ●● cardiac symptoms hours, increases the risk for a sudden cardiac ●● known (CAD) event [Kales et al. 2003; Hales et al. 2007; Kales ●● one or more risk factors* for CAD (in men et al. 2007]. older than 45 and women older than 55) ●● fire fighters with a Framingham Risk Score NIOSH investigators conclude the LT’s sudden > 10% [NHLBI 2013] cardiac death was due to a primary arrhythmia or a associated with his *Risk factors are defined as hypercholesterolemia underlying undiagnosed heart disease. Either (total cholesterol greater than 240 milligrams per

Page 5 A Summary of a NIOSH fire fighter fatality investigation Report #2013-28 Volunteer Lieutenant Suffers Sudden Cardiac Death at Fire Station While Doing Fitness Training – New York Discussion (cont.) deciliter), hypertension (diastolic blood pressure The U.S. Preventive Services Task Force greater than 90 mm of mercury), smoking, (USPSTF) does not recommend stress tests for diabetes mellitus, or family history of premature asymptomatic individuals at low risk for CHD CAD (heart attack or sudden cardiac death in a events. For individuals at increased risk for first-degree relative less than 60 years old). CHD events, the USPSTF found “insufficient evidence to recommend for or against routine The American College of Cardiology/American screening with EKG, exercise tolerance test, or Heart Association (ACC/AHA) has also published electron beam computerized tomography scanning exercise testing guidelines [Gibbons et al. 2002]. …” Rather, they recommend the diagnosis and The ACC/AHA guideline states the evidence treatment of modifiable risk factors (hypertension, is “less well established” (Class IIb) for the high cholesterol, smoking, and diabetes) [USPSTF following groups: 2004]. The USPSTF does note that “For people ● persons with multiple risk factors (defined in certain occupations, such as pilots, and similarly to those listed by the NFPA) heavy equipment operators (for whom sudden ● asymptomatic men older than 45 years and incapacitation or sudden death may endanger women older than 55 years: the safety of others), consideration other than ○ who are sedentary and plan to start vigor- the health benefit to the individual patient may ous exercise influence the decision to screen for coronary heart ○ who are involved in occupations in which disease.” impairment might jeopardize public safety (e.g., fire fighters) The LT had several risk factors for CHD (age, ○ who are at high risk for CAD due to other male gender, family history, hypertension) and at diseases (e.g., peripheral vascular disease autopsy was found to have severe atherosclerosis. and chronic renal failure) Available guidelines indicate that an exercise stress test was appropriate given the LT’s age (>45 The U.S. Department of Transportation provides years) and his other CHD risk factors. Had a stress guidance for those seeking medical certification for test been performed, perhaps his underlying CHD a commercial driver’s license. An expert medical could have been identified and treated. panel recommended exercise tolerance tests (stress tests) for asymptomatic “high risk” drivers Recommendations [Blumenthal et al. 2007]. The panel defines high NIOSH investigators offer the following risk drivers as those with any of the following: recommendations to reduce the risk of on-the-job ● diabetes mellitus heart attacks and sudden cardiac arrest among ● peripheral vascular disease fire fighters. ● age 45 and above with multiple risk factors for coronary heart disease Recommendation #1: Ensure that all fire fighters ● Framingham risk score predicting a 20% receive an annual medical evaluation consistent coronary heart disease event risk over the with NFPA 1582, Standard on Comprehensive next 10 years Occupational Medical Program for Fire Departments.

Page 6 A Summary of a NIOSH fire fighter fatality investigation Report #2013-28 Volunteer Lieutenant Suffers Sudden Cardiac Death at Fire Station While Doing Fitness Training – New York Recommendations (cont.) Guidance regarding the content and frequency and physician volunteers may reduce the negative of these medical evaluations can be found in financial impact on recruiting and retaining NFPA 1582 and in the International Association needed fire fighters. of Fire Fighters (IAFF)/International Association of Fire Chiefs (IAFC) Fire Service Joint Recommendation #2: Ensure fire fighters are Labor Management Wellness/Fitness Initiative cleared for duty by a physician knowledgeable (WFI) [NFPA 2013; IAFF, IAFC 2008]. These about the physical demands of firefighting, the evaluations are performed to determine fire personal protective equipment used by fire fighters, fighters’ medical ability to perform duties without and the various components of NFPA 1582. presenting a significant risk to the safety and health of themselves or others. While the FD According to NFPA 1582 and the IAFF/IAFC is following many of the components of NFPA Fire Service Joint Labor Management Wellness/ 1582, it is not conducting stress tests for fire Fitness Initiative, the FD should have an officially fighters at increased risk of coronary heart disease. designated physician who is responsible for Applying this recommendation involves economic guiding, directing, and advising the members repercussions and may be particularly difficult for with regard to their health, fitness, and suitability smaller fire departments to implement. The FD is for duty [NFPA 2013; IAFF/IAFC 2008]. The not legally required to follow the NFPA standard physician should review job descriptions and or the WFI guideline. essential job tasks required for all FD positions to understand the physiological and psychological To overcome the financial obstacle of medical demands of firefighting and the environmental evaluations, the FD could urge current members conditions under which fire fighters perform, as to get annual medical clearances from their private well as the personal protective equipment they physicians. Another option is having the annual must wear during various types of emergency medical evaluations completed by paramedics operations. In addition, this physician should and emergency medical technicians from the oversee all fitness for duty recommendations local ambulance service (vital signs, height, provided by PCP and have the final authority for weight, visual acuity, and electrocardiogram). all medical fitness for duty decisions. To ensure This information could then be provided to a the FD physician or other PCP is familiar with community physician, perhaps volunteering his or NFPA 1582, the NIOSH investigators recommend her time, who could review the data and provide the FD provide a copy or a link to the NFPA medical clearance or further evaluation, if needed. website where a copy could be purchased or The more extensive portions of the medical viewed on-line at no charge. evaluations could be performed by a private physician through the fire fighter’s personal Recommendation #3: Perform an annual physical insurance, provided by a physician volunteer, performance (physical ability) evaluation. or paid for by the FD, city, or state. Sharing the financial responsibility for these evaluations NFPA 1500, Standard on Fire Department between fire fighters, the FD, the city, the state, Occupational Safety and Health Program

Page 7 A Summary of a NIOSH fire fighter fatality investigation Report #2013-28 Volunteer Lieutenant Suffers Sudden Cardiac Death at Fire Station While Doing Fitness Training – New York Recommendations (cont.) recommends that the FD annually evaluate and primarily due to a reduction of occupational certify FD members who engage in emergency injury/illness claims with additional savings operations as having met the physical performance expected from reduced future non-occupational requirements identified in Paragraph 10.2.3 of healthcare costs [Kuehl 2007; Kuehl 2013]. The the standard [NFPA 2007]. This is recommended FD does not have a wellness/fitness program. to ensure that fire fighters are physically capable Given the FD’s structure, the National Volunteer of performing the essential job tasks of structural Fire Council program would be very helpful fire fighting. The physical ability test could be [USFA 2004]. NIOSH recommends a formal, performed as part of the FD’s training program. mandatory wellness/fitness program to ensure Recommendation #4: Phase in a mandatory all members receive the benefits of a health comprehensive wellness and fitness program for promotion program. fire fighters. References Guidance for fire department wellness/fitness AHA [2012]. Understand your risk of heart attack. programs to reduce risk factors for cardiovascular American Heart Association. [http://www.heart. disease and improve cardiovascular capacity is org/HEARTORG/Conditions/HeartAttack/Under- found in NFPA 1583, Standard on Health-Related standYourRiskofHeartAttack/Understand-Your- Fitness Programs for Fire Fighters, the IAFF/ Risk-of-Heart-Attack_UCM_002040_Article.jsp]. IAFC Fire Service Joint Labor Management Date accessed: December 2013. Wellness/Fitness Initiative, the National Volunteer Fire Council Health and Wellness Guide, and in Albert CM, Mittleman MA, Chae CU, Lee IM, Firefighter Fitness: A Health and Wellness Guide Hennekens CH, Manson JE [2000]. Triggering [USFA 2004; IAFF, IAFC 2008; NFPA 2008; of sudden death from cardiac causes by vigorous Schneider 2010]. Worksite health promotion exertion. N Engl J Med 343(19):1355–1361. programs have been shown to be cost effective by increasing productivity, reducing absenteeism, Aldana SG [2001]. Financial impact of health pro- and reducing the number of work-related injuries motion programs: a comprehensive review of the and lost work days [Stein et al. 2000; Aldana literature. Am J Health Promot 15:296-320. 2001]. Fire service health promotion programs have been shown to reduce CHD risk factors and Blevins JS, Bounds R, Armstrong E, Coast JR improve fitness levels, with mandatory programs [2006]. Health and fitness programming for fire showing the most benefit [Dempsey et al. 2002; fighters: does it produce results? Med Sci Sports Womack et al. 2005; Blevins et al. 2006]. A study Exerc 38(5):S454. conducted by the Oregon Health and Science University reported a savings of more than $1 million for each of four large fire departments implementing the IAFF/IAFC wellness/fitness program compared to four large fire departments not implementing a program. These savings were

Page 8 A Summary of a NIOSH fire fighter fatality investigation Report #2013-28 Volunteer Lieutenant Suffers Sudden Cardiac Death at Fire Station While Doing Fitness Training – New York References (cont.) Blumenthal RS, Epstein AE, Kerber RE [2007]. Hales T, Jackson S, Baldwin T [2007]. NIOSH Expert panel recommendations. Cardiovascular Alert: Preventing Fire Fighter Fatalities Due to disease and commercial motor vehicle driver Heart Attacks and Other Sudden Cardiovascular safety. [http://www.mrb.fmcsa.dot.gov/docu- Events. Department of Health and Human Ser- ments/CVD_Commentary.pdf]. Date accessed: vices, Public Health Service, Centers for Disease February 2013. Control and Prevention, National Institute for Occupational Safety and Health Publication No. CDC [2011]. Assessing your weight. Centers for 2007-133. [http://www.cdc.gov/niosh/docs/2007- Disease Control and Prevention. [http://www.cdc. 133/]. Date Accessed: December 2013. gov/healthyweight/assessing/index.html]. Date ac- cessed: December 2013. IAFF, IAFC [2008]. The fire service joint labor management wellness/fitness initiative. 3rd ed. Davies MJ [1992]. Anatomic features in victims Washington, DC: International Association of Fire of sudden coronary death. Coronary artery pathol- Fighters, International Association of Fire Chiefs. ogy. Circulation 85[Suppl I]:I-19–24. Kales SN, Soteriades ES, Christoudias SG, Chris- Dempsey WL, Stevens SR, Snell CR [2002]. tiani DC [2003]. Fire fighters and on-duty deaths Changes in physical performance and medical from coronary heart disease: a case control study. measures following a mandatory firefighter well- Environ Health 2(1):14. ness program. Med Sci Sports Exerc 34(5):S258. Kales SN, Soteriades ES, Christophi CA, Farb A, Tang AL, Burke AP, Sessums L, Liang Chirstiani DC [2007]. Emergency duties and Y, Virmani R [1995]. Sudden coronary death: deaths from heart disease among fire fight- frequency of active lesions, inactive coronary ers in the United States. New Engl J Med lesions, and myocardial infarction. Circulation 356(12):1207-1215. 92(7):1701–1709. Kelesidis I, Travin MI [2012]. Use of cardiac ra- Gibbons RJ, Balady GJ, Bricker JT, Chaitman dionuclide imaging to identify patients at risk for BR, Fletcher GF, Froelicher VF, Mark DB, Mc- arrhythmic sudden cardiac death. J Nucl Cardiol Callister BD, Mooss AN, O’Reilly MG, Winters 19(1):142–152. WL Jr., Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Russell Kuehl K [2007]. Economic impact of the wellness RO, Smith SC Jr. [2002]. ACC/AHA 2002 guide- fitness initiative. Presentation at the 2007 John P. line update for exercise testing: a report of the Redmond Symposium in Chicago, IL on October American College of Cardiology/American Heart 23, 2007. Association Task Force on Practice Guidelines. Circulation 106(14):1883–1892.

Page 9 A Summary of a NIOSH fire fighter fatality investigation Report #2013-28 Volunteer Lieutenant Suffers Sudden Cardiac Death at Fire Station While Doing Fitness Training – New York References (cont.) Kuehl KS, Elliot DL, Goldberg L, Moe EL, Per- NFPA [2013]. Standard on comprehensive oc- rier E, Smith J [2013]. Economic benefit of the cupational medical program for fire departments. PHLAME wellness programme on firefighter Quincy, MA: National Fire Protection Associa- injury. Occup Med 63(3):203-209. tion. NFPA 1582.

Libby P [2008]. The pathogenesis, prevention, NHLBI (National Heart, Lung, and Blood Insti- and treatment of atherosclerosis. In: Fauci AS, tute) [2013]. Risk assessment tool for estimating Braunwald E, Kasper DL, Hauser SL, Longo DL, your 10-year risk of having a heart attack. [http:// Jameson JL, Loscalzo J, eds. Harrison’s principles cvdrisk.nhlbi.nih.gov/calculator.asp] Date ac- of internal medicine. 17th ed. New York: Mc- cessed: December 2013. Graw-Hill, pp. 1501–1509. National Cholesterol Education Program [2002]. Mayo Clinic [2013]. Heart arrhythmias. [http:// Third Report of the National Cholesterol educa- www.mayoclinic.com/health/heart-arrhythmias/ tion Program (NCEP) Expert Panel on Detection, DS00290/METHOD=print&DSECTION=all]. Evaluation, and Treatment of High Blood Choles- Date accessed: January 2014. terol in Adults (Adult treatment Panel III). NIH Publication No. 02-5215. National Institutes of Mittleman MA, Maclure M, Tofler GH, Sherwood Health, National Heart, Lung, and Blood Institute. JB, Goldberg RJ, Muller JE [1993]. Triggering Washington: Government Printing Office. of acute myocardial infarction by heavy physical exertion. N Engl J Med 329(23):1677-1683. Schneider EL [2010]. Firefighter fitness: a health and wellness guide. New York: Nova Science Neumar RW, Otto CW, Link MS, Kronick SL, Publishers. Shuster M, Callaway CW, Kudenchuk PJ, Ornato JP, McNally B, Silvers SM, Passman RS, White Shah PK [1997]. Plaque disruption and coronary RD, Hess EP, Tang W, Davis D, Sinz E, Morrison thrombosis: new insight into pathogenesis and LJ [2010]. Part 8: Adult advanced cardiovascular prevention. Clin Cardiol 20(11 Suppl2):II-38–44. life support. 2010 American Heart Association Guidelines for cardiopulmonary resuscitation and Stein AD, Shakour SK, Zuidema RA [2000]. emergency cardiovascular care. Dallas, TX: Amer- Financial incentives, participation in employer ican Heart Association. sponsored health promotion, and changes in employee health and productivity: HealthPlus NFPA [2007]. Standard on fire department occu­ health quotient program. J Occup Environ Med pational safety and health program. Quincy, MA: 42(12):1148-1155. National Fire Protection Association. NFPA 1500.

NFPA [2008]. Standard on health-related fitness programs for fire fighters. Quincy, MA: National Fire Protection Association. NFPA 1583.

Page 10 A Summary of a NIOSH fire fighter fatality investigation Report #2013-28 Volunteer Lieutenant Suffers Sudden Cardiac Death at Fire Station While Doing Fitness Training – New York References (cont.) Tofler GH, Muller JE, Stone PH, Forman S, Solo- mon RE, Knatterud GL, Braunwald E [1992]. Modifiers of timing and possible triggers of acute myocardial infarction in the in Myocardial Infarction Phase II (TIMI II) Study Group. J Am Coll Cardiol 20(5):1049-1055.

USFA [2004]. Health and wellness guide. Em- mitsburg, MD: Federal Emergency Management Agency; United States Fire Administration. Publi- cation No. FA-267.

USPSTF [2004]. U.S. Prevention Services Task Force. Screening for coronary heart disease: Recommendation Statement. Ann Intern Med 140(7):569–572.

Willich SN, Lewis M, Lowel H, Arntz HR, Schubert F, Schroder R [1993]. Physical exertion as a trigger of acute myocardial infarction. N Engl J Med 329(23):1684-1690.

Womack JW, Humbarger CD, Green JS, Crouse SF [2005]. Coronary artery disease risk factors in firefighters: effectiveness of a one-year voluntary health and wellness program. Med Sci Sports Exerc 37(5):S385.

Page 11 A Summary of a NIOSH fire fighter fatality investigation Report #2013-28 Volunteer Lieutenant Suffers Sudden Cardiac Death at Fire Station While Doing Fitness Training – New York Investigator Information Appendix A Autopsy Findings This incident was investigated by the NIOSH Fire Fighter Fatality Investigation ● Heart size and structure and Prevention Program, Cardiovascular ○ Heart weight = 410 grams (expected Disease Component located in Cincinnati, weight 360 grams) [Silver and Silver 2001] Ohio. Denise L. Smith, Ph.D, led the ○ Mild-moderate dilation of both the right investigation and coauthored the report. Dr. and left ventricular chambers Smith is professor of Health and Exercise ○ Heart valves are in usual anatomic Sciences, and Director of the First Responder positions and are without gross Health and Safety Laboratory at Skidmore abnormalities with the exception of College. She is a member of the NFPA the , which shows mild Technical Committee on Occupational myxomatous degeneration but no Safety and Health. Dr. Smith was working interchordal hooding as a contractor with the NIOSH Fire Fighter ● Coronary arteries Fatality Investigation and Prevention ○ Coronary arteries show normal Program, Cardiovascular Disease Component corse and caliber and the right-sided during this investigation. Thomas Hales, circulation is dominant MD, MPH, provided medical consultation ○ High-grade calcified atherosclerotic and coauthored the report. Dr. Hales is a lesions involving major coronary arteries member of the NFPA Technical Committee ○ 99% luminal stenosis of the mid right on Occupational Safety and Health, and Vice coronary artery Chair of the Public Safety Medicine Section ○ 90% luminal stenosis of the left anterior of the American College of Occupational and descending artery Environmental Medicine (ACOEM). ○ 90% luminal stenosis of the left marginal branch ○ No coronary thrombosis ot plaque hemorrhage identifed

References Silver MM, Silver MD [2001]. Examination of the heart and of cardiovascular specimens in surgical pathology. In: Silver MD, Gotlieb AI, Schoen FJ, eds. Cardiovascular pathology. 3rd ed. Philadel- phia, PA: Churchill Livingstone, pp. 8–9.

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