2007 Death in the 15 Fire Fighter Fatality Investigation and Prevention Program line of duty…

A summary of a NIOSH fire fighter fatality investigation January 30, 2008

Captain Suffers Sudden Cardiac Death During Physical Fitness Evaluation - Alabama

SUMMARY • Incorporate exercise stress tests into the Fire Department’s medical On April 25, 2007, a 56-year-old male career evaluation program. Captain was participating in the Fire Department’s annual “Fit Check” (physical • Provide fire fighters with medical fitness) evaluation. The Captain successfully evaluations and clearance to wear completed the bench press, sit-ups, and sit­ self-contained breathing apparatus and-reach portions of the evaluation within the (SCBA). allotted time. During the aerobic capacity (3­ mile walk) portion of the evaluation, he • Provide exercise equipment in all fire completed 6 of 12 laps around the ¼-mile stations. track, when he suddenly collapsed. Crew members on the scene responded and found • Ensure that all members participate in him unresponsive, not breathing, and with a the Fire Department’s mandatory weak pulse that stopped shortly thereafter. wellness/fitness program. Approximately 29 minutes later, despite cardiopulmonary resuscitation (CPR) and advanced life support administered on-scene INTRODUCTION and METHODS and at the hospital, the Captain died. The death certificate and the autopsy, completed by the On April 25, 2007, a 56-year-old male Captain County Medical Examiner, listed lost consciousness while participating in the “complications of atherosclerotic Fire Department annual physical fitness ” as the immediate evaluation. Despite CPR and advanced life cause of death with “” as a significant condition. The Fire Fighter Fatality Investigation and Prevention NIOSH investigators offer the following Program is conducted by the National Institute for recommendations to address general safety Occupational Safety and Health (NIOSH). The purpose of and health issues. However, it is unclear if any the program is to determine factors that cause or contribute of these recommendations would have to fire fighter deaths suffered in the line of duty. prevented the Captain’s sudden cardiac death. Identification of causal and contributing factors enable researchers and safety specialists to develop strategies for preventing future similar incidents. The program does not • Provide mandatory annual medical seek to determine fault or place blame on fire departments evaluations to all fire fighters to or individual fire fighters. To request additional copies of ensure their medical ability to perform this report (specify the case number shown in the shield fire fighting duties without presenting above), other fatality investigation reports, or further information, visit the Program Website at a significant risk to the safety and http://www.cdc.gov/niosh/fire/ health of themselves or others. or call toll free 1–800–CDC–INFO (1–800–232–4636) 2007 Fatality Assessment and Control Evaluation Fire Fighter Fatality Investigation Investigation Report # F2007-15 and Prevention Program

Captain Suffers Sudden Cardiac Death During Physical Fitness Evaluation - Alabama support administered by crew members, the • Fire Department annual report for 2006 Fire Department ambulance crew, and in the • Fire Department incident report emergency department, the Captain died. NIOSH was notified of this fatality on April • Emergency medical service 26, 2007, by the United States Fire (ambulance) incident report Administration. On May 9, 2007, NIOSH • Death certificate contacted the affected Fire Department to gather additional information and on June 6, • Autopsy record 2007 to initiate the investigation. On June 25, • Primary care provider medical records 2007, a Safety and Occupational Health Specialist from the NIOSH Fire Fighter Fatality Investigation Team traveled to Alabama to conduct an on-site investigation of INVESTIGATIVE RESULTS the incident. On April 25, 2007, the Captain reported for During the investigation, NIOSH personnel duty at his fire station (Station 16) at 0800 interviewed the following people: hours. During the morning hours, the Captain performed station duties including paperwork • Fire Chief and responding to a medical call for patient • Assistant Fire Chief transport (1119 hours). The Captain, who was assigned to Rescue 16, provided basic medical • Battalion Chief of Safety care during the transport. After the call, • Fire Department Safety Officer Rescue 16 returned to their fire station and the crew ate lunch. Due to the scheduled “Fit • Fire Department Chaplain Check” evaluation that afternoon, the Captain • Crew members drank more fluids than usual. • Captain’s family Engine 2, Engine 9, Engine 31, Truck 2, and Rescue 16 were scheduled to perform their NIOSH personnel reviewed the following annual “Fit Check” at 1330 hours. A total of documents: 22 fire fighters participated in the evaluation, • Fire Department policies and operating and 9 monitoring personnel (exercise guidelines physiologists, paramedics, and the Fire Department’s Safety Officer) were available • Fire Department physical examination for medical and rehabilitation (water, etc.) protocols support. Participants wore gym shorts, T-shirt, • Fire Department fitness (“Fit Check”) and gym shoes. The first part of the “Fit protocols Check”, conducted at the City Fitness Center, included: • Fire Department training records • vital signs (resting heart rate and blood pressure)

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Captain Suffers Sudden Cardiac Death During Physical Fitness Evaluation - Alabama

• body composition measurements Table 1 shows the Captain’s lap times. (chest, abdomen, thigh, and % body fat) Table 1: Lap Times During the Captain’s 3­ mile “Fit Check” Walk • upper body strength (maximum bench press, 1 repetition) Lap 1: 3 minutes and 30 seconds • abdomen strength (maximum number Lap 2: 7 minutes of bent-knee sit-ups in 1 minute) Lap 3: 10 minutes and 30 seconds Lap 4: 13 minutes and 50 seconds • flexibility (sit and reach beyond the Lap 5: 17 minutes and 17 seconds toes) Lap 6: 21 minutes and 29 seconds Lap 7: collapsed Points were awarded based on tasks accomplished and the participant’s age. The Captain scored 50 points on body composition The Captain was given a cup of water on lap 5 (poor), 75 points on upper body strength and was sweating a moderate amount. A (average), 75 points on abdomen strength monitor asked the Captain if he was okay, to (average), and 80 points on flexibility which the Captain nodded and said “yes.” The (average). During the first portion of the Captain chatted with other crew members and evaluation, the Captain did not report any did not show any unusual signs of distress. As symptoms or show any signs of heart the Captain was three-fourths of the way problems. through Lap 7, he struggled to breathe, and then suddenly collapsed (1438 hours). The “Fit Check” participants drove to the track for the aerobic portion of the evaluation. The Crew members responded immediately and aerobic portion consisted of either a 1½-mile found him unresponsive, not breathing, and run or a 3-mile walk on an oval paved track (1 with a weak pulse that stopped shortly lap equaled ¼-mile). The Captain selected the thereafter. Fire Alarm was notified. CPR 3-mile walk (12 laps) which must be (assisted ventilations provided with a bag­ completed within 47 minutes for a passing valve-mask) was begun as a cardiac monitor score. Roll call was performed, and was attached, revealing ventricular participants were asked by the Safety Officer (a heart rhythm incompatible with life). The if anyone felt they should not, or could not, Captain was defibrillated (shocked) once; his participate in the walk/run; no one declined. heart rhythm reverted to (no heart The Safety Officer briefed participants that beat). Chest compressions were begun, an cold water was available and that two intravenous line was placed, and intravenous paramedics (Rescue 27) were available with medications consistent with advanced life medical equipment if needed. The weather support were administered. Intubation conditions at this time included a temperature (breathing tube inserted into the trachea) was of about 79° F, with 44% relative humidity.1 attempted without success.

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Captain Suffers Sudden Cardiac Death During Physical Fitness Evaluation - Alabama

The Captain was placed onto a stretcher and • Cardiomegaly (heart weighed 490 grams into Rescue 27, which departed the scene at [g]) (normal weight is <400 g)2 1442 hours. During the transfer, the • No “obvious significant left ventricular intravenous line pulled out. A second hypertrophy” intubation attempt in Rescue 27 was successful, and cardiac resuscitation • No evidence of a pulmonary embolus medications were administered via the (blood clot in the lung arteries) endotracheal tube. En route, advanced life • Negative drug and alcohol tests support procedures and CPR continued. Rescue 27 arrived at the hospital at 1446 The Captain was 73 inches tall and weighed hours. Inside the Emergency Department, 241 pounds, giving him a body mass index CPR and advanced life support measures (BMI) of 31.79. A BMI >30.0 kilograms per continued until 1507 hours, when the Captain meters squared (kg/m2) is considered obese.3 was pronounced dead by the attending The Captain had a history of hypertension and physician. was prescribed an antihypertensive medication. Although his blood cholesterol Medical Findings. The death certificate and level was normal, his cholesterol/HDL ratio autopsy, completed by the County Medical had been high (> 5.77) since 1998. Examiner on April 26, 2007, listed “complications of atherosclerotic In 2002, the Captain was referred to a cardiovascular disease” as the immediate cardiologist due to chest discomfort and cause of death with “cardiomegaly” as a on exertion. An imaging significant condition. Pertinent findings from stress test (cardiolite single photon emission the autopsy included: computed tomography [SPECT] study) was • Atherosclerotic conducted using the Bruce protocol.4 The (CAD) Captain exercised for 10 minutes, 12 seconds (10 metabolic equivalents [METS]) reaching a o Severe (95%) focal narrowing of the circumflex coronary artery peak heart rate of 156 beats per minute (92% of his maximum). No ischemic ST-T wave o Moderate (50%) focal narrowing of the left anterior descending coronary changes were seen during exercise, nor were artery any perfusion defects identified (e.g., no evidence of or scar formation). o Moderate (50%) focal narrowing of the right coronary artery Doppler echocardiography revealed normal heart valves, normal left ventricular ejection • Intramural scar of the posterior wall fraction (60%), and borderline/mild left consistent with a remote (old) . The cardiologist (heart attack) diagnosed the Captain as having Stage I • Myocardial bridging of the distal left hypertension, currently without anterior descending and marginal branch antihypertensive therapy, and mild left of the circumflex ventricular hypertrophy.

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Captain Suffers Sudden Cardiac Death During Physical Fitness Evaluation - Alabama

According to his family and crew members, program is based on the State minimum since 2002 the Captain had no complaints of requirement for fire fighter certification. chest pains, unusual shortness of breath on Recurrent training occurs daily on each shift. exertion, or any other heart-related illness. There is no State requirement for fire fighter re-certification. Annual re-certification is required for Hazardous Materials, while DESCRIPTION OF THE FIRE biannual re-certification is required for DEPARTMENT Apparatus/Operator and EMT/Paramedics. The Captain was certified as a Fire Fighter II, At the time of the NIOSH investigation, the Fire Officer II, Fire Service Instructor I, Fire Department consisted of 647 uniformed Driver/Operator, EMT-Paramedic, and personnel and served a population of 242,000 HazMat Technician. He had 23 years of residents in a geographic area of 165 square firefighting experience. miles. There are 31 fire stations. Fire fighters work the following schedule: 24-hours on- Pre-placement Medical Evaluations. The Fire duty, 48-hours off-duty, from 0800 hours to Department requires a pre-placement medical 0800 hours. evaluation for all new hires, regardless of age. Components of this evaluation include the In 2006, the Fire Department responded to following: 51,690 calls: 31,959 advanced life support calls, 10,544 basic life support calls, 9,134 fire • A complete medical history calls, and 53 fire/medical calls. The day prior • Physical examination (including vital to the incident, the Captain ran errands and signs) worked at a charity golf event. • Complete blood count with lipid panel • Pulmonary function test (PFT) Employment and Training. The Fire • Audiogram Department requires all new fire fighter • Vision screen applicants to pass a written test, a Job Task • Urinalysis evaluation (described below), an interview, a • Urine drug screen physical examination, and a drug screen prior • Resting EKG to being hired. New fire fighter applicants are • Chest x-ray (baseline) also given a fitness evaluation. Newly hired • Mantoux tuberculosis (TB) test fire fighters are then sent to the 18-week fire fighter training course at the City Fire • Hepatitis B Titer (if previously Academy to become certified as a Fire Fighter immunized) I and II, emergency medical technician (EMT) and to the Hazardous Materials (HazMat) These evaluations are performed by a operations level. physician contracted by the City. Once this evaluation is complete, the contracted Recruits must complete monthly training physician makes a determination regarding modules for one year. The recruit training medical clearance for firefighting duties and

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Captain Suffers Sudden Cardiac Death During Physical Fitness Evaluation - Alabama forwards this decision to the City’s personnel • Body composition director. • Upper body strength (bench press: maximum weight, 1 repetition) Periodic Medical Evaluations. Periodic • Abdomen strength (sit-ups performed (annual) medical evaluations are not required in 1 minute) by the Fire Department for all fire fighters, • Flexibility (sit and reach) only for fire fighters with City health • Aerobic capacity/cardiorespiratory insurance. For fire fighters with City health endurance (timed 1½-mile run or a 3­ insurance, the annual medical evaluation can mile walk) be performed by the fire fighter’s personal • Lifestyle assessment physician or the City’s contract physician. The • Nutrition assessment components of this evaluation depends on who conducts the evaluation: A member who cannot perform the “Fit Check”, fails to complete any component, does Good Health Program not achieve an average score of 75% on the • Blood pressure first four components, or does not achieve • Blood work 75% on the cardiovascular component • Height, weight, BMI (walk/run) is rescheduled for another “Fit • Pulmonary function test Check” evaluation in about 2 weeks. If a fire • Hearing fighter fails to achieve an average score of • Vision 75% on the follow-up evaluation, the City Fitness Director and the Fire Department Personal Physician Training/Safety Division will develop a • Unknown program for the fire fighter that will strengthen areas of physical deficiency. These members Regardless of which physician performs the are re-evaluated every month until an average evaluation, the Fire Department does not score of 75% is achieved. An evaluation by the require a medical clearance for full duty. Medical Services Unit may be required for members who fail to make improvement. Members who fail to pass on their targeted WELLNESS and HEALTH date or fail to make expected improvements in meeting their goals are scheduled for a hearing “Fit Check” Evaluation. A “Fit Check” with the Occupational Health and Safety evaluation is performed prior to the annual Job Committee. Task evaluation. Components of the “Fit Check” include: Members with a systolic blood pressure of 150 mmHg and above, or a diastolic blood pressure • Height, weight, vital signs (blood of 100 mmHg and above, are not allowed to pressure <150/100 millimeters of participate in the “Fit Check” or engage in mercury [mmHg]) emergency operations and are placed on sick

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Captain Suffers Sudden Cardiac Death During Physical Fitness Evaluation - Alabama leave. The Training/Safety Division provides • Hydrant evolution: The participant the fire fighter with a medical release form to must uncap the hydrant, and then be completed by the member’s personal attach the 3-inch hose to the hydrant. physician, stating the member is capable of The hydrant is then fully opened and performing firefighting duties. The medical then closed. The hose is disconnected release form must be submitted to the Safety and the cap is replaced on the hydrant, Division prior to returning to full duty. As all within 2 minutes, 10 seconds. recommended by the Fire Department Safety • Tower climb: The participant dons an Officer, an evaluation by the Medical Services SCBA (without the facepiece) and Unit may be required. places a standpipe package, consisting of two sections of 1¾-inch hose, on Job Task Evaluation. The Job Task evaluation one shoulder. At the starting line, the is completed with the participant wearing full participant climbs the outside stairs of bunker gear. The Job Task evaluation consists the drill tower to the fifth floor and of: places the standpipe package in the fifth floor window. The participant • Hose hoist: While standing on the then climbs the ladder to the roof of the ground, the participant hoists one tower and climbs down the roof ladder section of 1¾-inch hose to the fourth to the interior of the fifth floor. The story of the drill tower utilizing a fixed participant then goes to the fifth floor pulley, lowers the hose to the ground, window, places the standpipe package and then repeats the procedure within 1 back on one shoulder, goes down the minute, 15 seconds. interior stairs, and exits the first floor • Hose pull: The participant places the 3­ doorway, all within 3 minutes, 30 inch uncharged hose nozzle on their seconds. shoulder and pulls the 3-inch hose from a starting point until the nozzle crosses To pass the Job Task, the fire fighter must the finish line, 150-feet away, within complete all tasks within the allotted 35 seconds. comprehensive time of 11 minutes, 15 • Dummy (manikin) drag: The dummy is seconds. If a fire fighter cannot perform or lying on the ground with the head fails to complete any component of the Job toward the finish line and the Task evaluation in the allotted time, he/she is participant behind the start line. The rescheduled for another Job Task evaluation in participant assumes a position over the about 2 weeks. Personnel who fail the Job dummy with the participant’s arm Task evaluation two times are placed on under the dummy’s arms. The administrative assignment to the participant pulls the dummy 50-feet Safety/Training Division and are required to until the dummy’s head crosses the enter a physical performance rehabilitation back of the finish line within 30 program conducted by the City Fitness Center seconds. Director. These members are not permitted to

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Captain Suffers Sudden Cardiac Death During Physical Fitness Evaluation - Alabama engage in emergency operations. Line DISCUSSION personnel failing the Job Task after completing a work hardening program, or failing a third The Captain’s sudden cardiac death is time, remain on administrative assignment probably related to one or more of the pending a determination whether they may following conditions: return to emergency operations. This determination is based on evaluations by the 1) Atherosclerotic coronary artery disease City Physician and/or Fitness Director. (CAD) 2) Myocardial bridging If an employee is injured at work, they are 3) Mild left ventricular hypertrophy placed on Injured With Pay (IWP) and under 4) Cardiomegaly the care of the City Physician. If an employee 5) Physical exertion associated with the is ill or has an injury that is not job related and “Fit Check” off work for more than one 24-hour shift (or more than three occurrences within 12 In the United States, atherosclerotic CAD is months), the employee must be evaluated by the most common risk factor for his/her personal physician. Fire fighters and sudden cardiac death.5 Risk factors for its assigned to operations who are returning from development include age over 45, male an extended leave of 30 days or more may be gender, family history of CAD, high blood required to be evaluated by the Medical pressure, high blood cholesterol, obesity, Services Unit, and successfully complete a Job physical inactivity, and diabetes.6-7 The Task evaluation and/or Fit Check prior to Captain had four of these risk factors (age over returning to regular duties. An employee may 45, male gender, hypertension, and mild be required to provide a proof of illness form obesity). if sick leave abuse is suspected. Light duty positions are available for employees who The narrowing of the coronary arteries by have been ill or injured and obtain a medical atherosclerotic plaques occurs over many release from their personal physician. If the years, typically decades.8 However, the growth fire fighter is incapable of returning to of these plaques probably occurs in a firefighting duties, he/she is re-assigned to a nonlinear, often abrupt fashion.9 Heart attacks non-emergency position within the City typically occur with the sudden development system (contingent on availability). of complete blockage (occlusion) in one or Exercise (strength and aerobic) equipment is more coronary arteries that have not developed located in 24 of the 30 fire stations. Fire a collateral blood supply.10 This sudden fighters also have access to the City Health blockage is primarily due to blood clots and Fitness Center. The Fire Department (thromboses) forming on the top of maintains a mandatory, on-duty atherosclerotic plaques. wellness/fitness program, however, participation is less than 100%. Health Establishing the occurrence of a heart attack maintenance programs are also available from requires any of the following: characteristic the City. EKG changes, elevated cardiac enzymes, or

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Captain Suffers Sudden Cardiac Death During Physical Fitness Evaluation - Alabama coronary artery thrombus. In the Captain’s associated with sudden cardiac death,21-24 case, he never regained a heart rhythm on ischemia,25-27 myocardial infarction,28-32 which an EKG could reveal characteristic ,33-35 and coronary artery spasm.36 changes, cardiac enzyme testing was not Because myocardial bridging is a relatively performed (but the enzymes do not become common finding at autopsy, its role in positive for at least 4 hours post-heart triggering the Captain’s sudden cardiac death attack),11 and no thrombus was found at is unclear. autopsy. However, not all heart attacks have an associated coronary artery thrombus. Given Left Ventricular Hypertrophy and the autopsy findings of severe focal CAD and Cardiomegaly. On autopsy, the Captain had an a posterior wall scar consistent with a remote enlarged heart. This enlargement was probably (old) heart attack, it is possible the Captain due to his mild left ventricular hypertrophy suffered another “silent” heart attack. The lack diagnosed by echocardiogram in 2002. The of does not rule out a heart attack echocardiogram described his left ventricular because in up to 20% of individuals, the first hypertrophy as “concentric;” a finding evidence of CAD may be myocardial consistent with his long standing high blood infarction or sudden death.8,12 pressure. Left ventricular hypertrophy and cardiomegaly are both associated with an Epidemiologic studies have found that heavy increased risk of sudden cardiac death.2, 37-39 physical exertion sometimes immediately precedes and triggers the onset of acute heart Occupational Medical Standards for attacks.13-16 The Captain had completed the Structural Fire Fighters. To reduce the risk of Fitness Center portion of the “Fit Check” and heart attacks and sudden cardiac arrest among half of the 3-mile walk. This activity expended fire fighters, the NFPA has developed about 4-6 METs, which is considered guidelines entitled “Standard on moderate physical activity.17-19 Given the Comprehensive Occupational Medical Captain’s underlying CAD, the physical stress Program for Fire Departments,” of performing the “Fit Check” evaluation otherwise known as NFPA 1582.40 NFPA could have triggered a heart attack, causing his recommends annual medical evaluations to subsequent cardiac arrest and death. include an EKG. Had an EKG been conducted as part of a Fire Department annual medical Myocardial Bridging. Myocardial bridging is evaluation over the past five years, perhaps the defined as occurring when a portion of a Captain’s left ventricular hypertrophy would coronary artery tunnels into the myocardium, have been detected. This may have led to creating a muscle-bridge overlap. Myocardial further medical evaluation and treatment. bridging is very common. It has been reported in 0.5% to 16% of angiographic studies, and In addition to screening for risk factors for 15% to 85% of autopsies.20 Compression of CAD, NFPA 1582 recommends conducting the coronary artery due to the muscular band stress tests on members over the age of 45 occurs during systole, and sometimes extends with two or more CAD risk factors into diastole. Myocardial bridging has been (hypercholesterolemia, hypertension, smoking,

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Captain Suffers Sudden Cardiac Death During Physical Fitness Evaluation - Alabama diabetes mellitus, or family history or of Fire Chiefs (IAFC) Fire Service Joint Labor premature CAD).40 These recommendations Management Wellness/Fitness Initiative.42 are similar to those of the American College of However, the Fire Department is not legally Cardiology (ACC)/American Heart required to follow this standard or this Association (AHA).41 The Captain had one initiative. Nonetheless, we recommend the current “NFPA” risk factor for CAD City and Union work together to establish the (hypertension) but had previously smoked, content in order to be consistent with the quitting in 2002. Therefore, he would have above guidelines. Chapters 8-7.1 and 8-7.243 met the criteria prior to 2002, and regular of NFPA 1500, Standard on Fire Department stress testing would have been appropriate. Occupational Safety and Health Program, Although stress tests are not required by this address the economic issues. To overcome the Fire Department, the Captain did have an financial obstacle, the Fire Department could imaging stress test performed by his private urge current members to get annual medical physician in 2002, which was reported as clearances from their private physicians. This “unremarkable for reversible ischemia.” clearance would then be reviewed by the City physician, who would make the final determination of medical clearance. RECOMMENDATIONS Recommendation #2: Incorporate exercise stress tests into the Fire Department’s NIOSH investigators offer the following medical evaluation program. recommendations to address general safety and health issues. However, it is unclear if any NFPA 1582, the IAFF/IAFC Fire Service of these recommendations would have Joint Labor Management Wellness/Fitness prevented the Captain’s sudden cardiac death. Initiative, and the ACC/AHA recommend an exercise stress test for fire fighters with two or Recommendation #1: Provide mandatory more CAD risk factors.40-42 The exercise stress annual medical evaluations to all fire fighters test could be conducted by the fire fighter’s to ensure their medical ability to perform fire personal physician or the City contract fighting duties without presenting a physician. If the fire fighter’s personal significant risk to the safety and health of physician conducts the test, the results must be themselves or others. communicated to the City physician, who should be responsible for decisions regarding NFPA 1582 requires fire departments to medical clearance for firefighting duties. conduct pre-placement and annual medical evaluations to ensure fire fighters are Had a symptom-limiting exercise stress test medically capable of fire fighting duties. been performed and the Captain’s underlying Guidance regarding the content and frequency cardiac disease been identified, further of these evaluations can be found in NFPA 40 evaluated, and treated, perhaps his sudden 1582 and in the International Association of cardiac death could have been prevented at Fire Fighters (IAFF)/International Association this time.

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Captain Suffers Sudden Cardiac Death During Physical Fitness Evaluation - Alabama

Recommendation #3: Provide fire fighters emergency responses and daily work duties, with medical evaluations and clearance to the facility may not be convenient and thus, wear self-contained breathing apparatus underutilized. The fire companies may also (SCBA). have to be taken out of service during the time of exercise, depending on the location of the The Occupational Safety and Health facility. Even though this Fire Department has Administration (OSHA)’s Revised Respiratory a mandatory wellness/fitness program, fire Protection Standard requires employers to companies are not taken out of service (due to provide medical evaluations and clearance for staffing levels) to participate in the program. employees using respiratory protection.44 Locating the equipment in the fire stations These clearance evaluations are required for allows the fire fighters to exercise within the private industry employees and public constraints of their daily work schedules and employees in States operating OSHA- emergency responses, while remaining more approved State plans. Alabama is not a State- readily available for response. plan State; therefore, public sector employers are not required to comply with OSHA Recommendation #5: Ensure that all standards. However, we recommend following members participate in the Fire Department’s this standard for safety reasons, and a copy of mandatory wellness/fitness program. the OSHA medical checklist has been provided to the Fire Department. This Physical inactivity is the most prevalent clearance should not involve any additional modifiable risk factor for CAD in the United expense for the Fire Department. States. Physical inactivity, or lack of exercise, is associated with other risk factors, including Recommendation #4: Provide exercise obesity and diabetes.46 We applaud the Fire equipment in all fire stations. Department for developing a written, mandatory wellness/fitness program. Currently, 24 of the fire stations have strength However, compliance with the policy is not and aerobic exercise equipment. Also, fire universally applied. Guidance for fighters have access to the City Health and implementation and components of a Fitness Center. We applaud the City for these wellness/fitness program are found in NFPA facilities. However, NFPA 1583, Standard on 1583,45 in the IAFF/IAFC's Fire Service Joint Health-Related Fitness Programs for Fire Labor Management Wellness/Fitness Fighters, recommends providing exercise Initiative,42 and NFPA 1500.43 Wellness equipment through the contracted use of a programs have been shown to be cost public gym or other facility, or placing the effective, typically by reducing the number of equipment directly in all fire stations.45 work-related injuries and lost work days.47-49 Contracting the use of a facility requires a Health promotion programs in the fire service company (engine, ladder, etc.) of fire fighters have been shown to reduce CAD risk factors to exercise at the same time daily at a location and improve fitness levels, with mandatory separate from their fire station. The gym programs showing the most benefit.50-52 One should be centrally located, but due to mandatory program was able to show a cost

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Captain Suffers Sudden Cardiac Death During Physical Fitness Evaluation - Alabama savings of $68,741 due to reduced 5. Meyerburg RJ, Castellanos A [2005]. absenteeism.53 A similar cost savings has been Cardiovascular collapse, cardiac arrest, reported by the wellness program at the and sudden cardiac death. In: Kasper DL, Phoenix Fire Department, where a 12-year Braunwald E, Fauci AS, Hauser SL, commitment has resulted in a significant Longo DL, Jameson JL, eds. Harrison’s reduction in their disability pension costs.54 principles of internal medicine. 16th ed. New York: McGraw-Hill, pp. 1618-1624.

REFERENCES 6. AHA [1998]. AHA scientific position, risk factors for coronary artery disease. Dallas, TX: American Heart Association. 1. US Department of Commerce: National Oceanic & Atmospheric Administration 7. Jackson E, Skerrett PJ, Ridker PM [2001]. (NOAA) [2007]. Quality controlled local Epidemiology of arterial thrombosis. In: climatological data, hourly observations Coleman RW, Hirsh J, Marder VIJ, et al. eds. table, Birmingham International Airport, Homeostasis and thrombosis: basic principles Birmingham, AL. and clinical practice. 4th ed. Philadelphia, PA: [http://cdo.ncdc.noaa.gov/qclcd/QCLCD]. Lippincott Williams and Wilkins. Date accessed: July 2007. [Note: on this Web site, one must identify data before or 8. Libby P [2005]. The pathogenesis of after 2005]. atherosclerosis. In: Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, 2. Siegel RJ [1997]. Myocardial hypertrophy. Jameson JL, eds. Harrison’s principles of In: Bloom S, ed. Diagnostic criteria for internal medicine. 16th ed. New York: cardiovascular pathology acquired McGraw-Hill, pp. 1425-1430. diseases. Philadelphia, PA: Lippencott- Raven, pp. 55-57. 9. Shah PK [1997]. Plaque disruption and : new insight into 3. National Heart Lung Blood Institute pathogenesis and prevention. Clin Cardiol [2003]. Obesity education initiative. 20 (11 Suppl2):II-38-44. [http://www.nhlbisupport.com/bmi/ bmicalc.htm]. Date accessed: August 10. Fuster V, Badimon JJ, Badimon JH [1992]. 2007. The pathogenesis of coronary artery disease and the acute coronary syndromes. 4. Sport Fitness Advisor [2007]. The Bruce N Engl J Med 326:242-250. treadmill test. [http://www.sport-fitness­ advisor.com/bruce-treadmill-test.html]. 11. AHA [2006]. Blood tests for rapid detection Date accessed: August 2007. of heart attacks. Dallas, TX: American Heart Association. [http://www.americanheart.org/ presenter.jhtml?identifier=4477]. Date accessed: July 2006.

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12. Thaulow E, Erikssen J, Sandvik L, 18. Ainsworth BE [2003]. The compendium of Erikssen G, Jorgensen L, Cohn PF [1993]. physical activities. President’s Council on Initial clinical presentation of cardiac Physical Fitness and Sports: 4(2). disease in asymptomatic men with silent Washington, DC. myocardial ischemia and angiographically documented coronary artery disease (The 19. Ainsworth BE, Haskell WL, Leon AS, Oslo Ischemia Study). Am J Cardiol Jacobs DR Jr, Montoye HJ, Sallis JF, 72:629-633. Paffenbarger RS [1993]. Compendium of physical activities: classification of energy 13. Willich SN, Lewis M, Lowel H, Arntz HR, costs of human physical activities. Med Schubert F, Schroder R [1993]. Physical Sci Sports Exerc 25(1):71-80. exertion as a trigger of acute myocardial infarction. N Engl J Med 329:1684-1690. 20. Mohlenkamp S, Hort W, Junbo G, Erbel R [2002]. Update on myocardial bridging. 14. Mittleman MA, Maclure M, Tofler GH, Circulation 106:2616-2622. Sherwood JB, Goldberg RJ, Muller JE [1993]. Triggering of acute myocardial 21. Bestetti RB, Costa RS, Kazava DK, infarction by heavy physical exertion. N Olivera JSM [1991]. Can isolated Engl J Med 329:1677-1683. myocardial bridging of the left anterior descending coronary artery be associated 15. Siscovick DS, Weiss NS, Fletcher RH, with sudden death during exercise? Acta Lasky T [1984]. The incidence of primary Cardiol XLVI:27-30. cardiac arrest during vigorous exercise. N Engl J Med 311:874-877. 22. Desseigne P, Tabib A, Loire R [1991]. Myocardial bridging of the left anterior 16. Tofler GH, Muller JE, Stone PH, Forman descending coronary artery and sudden S, Solomon RE, Knatterud GL, Braunwald death: an autopsy study of 19 cases. Arch E [1992]. Modifiers of timing and possible Mal Coeur Vaiss 84:511-516. triggers of acute myocardial infarction in the Thrombolysis in Myocardial Infarction 23. Cutler D, Wallace JM [1997]. Myocardial Phase II (TIMI II) Study Group. J Am Coll bridging in a young patient with sudden Cardiol 20:1049-1055. death. Clin Cardiol 20(6):581-583.

17. American Industrial Hygiene Association 24. Morales A, Romanelli R, Boucek R Journal [1971]. Ergonomics guide to [1980]. The mural left anterior descending assessment of metabolic and cardiac costs coronary artery, strenuous exercise and of physical work. Am Ind Hyg Assoc J sudden death. Circulation 62:230-237. 560-564.

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25. Furniss SS, Williams DO, McGregor CG 32. Chee TP, Jensen DP, Padnick MB, Cornell [1990]. Systolic coronary occlusion due to WP, Desser KB [1981]. Myocardial myocardial bridging-a rare cause of bridging of the left anterior descending ischemia. Int J Cardiol 26(1):116-117. coronary artery resulting in subendocardial infarction. Arch Intern Med 141:1703­ 26. Ge J, Erbel R, Rupprecht HJ, Koch L, 1704. Kearney P, Gorge G, Haude M, Meyer J [1994]. Comparison of intravascular 33. den Dulk K, Brugada P, Braat S, Heddle B, ultrasound and in the Wellens HJ [1983]. Myocardial bridging assessment of myocardial bridging. as a cause if paroxysmal atrioventricular Circulation 89(4):1725-1732. block. J Am Coll Cardiol 1(3):965-969.

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30. van Brussel BL, van Tellingen C, Ernst 37. Siegel RJ [1997]. Cardiomegaly. In: MP, Plokker HW [1984]. Myocardial Bloom S, ed. Diagnostic criteria for bridging: a cause of myocardial infarction? cardiovascular pathology acquired Int J Cardiol 6:78-82. diseases. Philadelphia, PA: Lippencott- Raven, p. 12. 31. Bestetti RB, Finzi LA, Amaral FT, Secches AL, Olivera JS [1987]. 38. Bigger, Jr. JT [1994]. Role of left Myocardial bridging of coronary arteries ventricular ejection fraction. In: Akhtar M, associated with an impending acute Myerburg RJ, and Ruskin JN, eds. Sudden myocardial infarction. Clin Cardiol cardiac death. Philadelphia PA: Williams 10:129-131. & Wilkins, p. 191.

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39. Siegel RJ [1997]. Cardiac dilation. In: 45. NFPA [2000]. NFPA 1583: Standard on Bloom S, ed. Diagnostic criteria for health-related fitness programs for fire cardiovascular pathology acquired fighters. Quincy, MA: National Fire diseases. Philadelphia, PA: Lippencott- Protection Association. Raven, pp. 11-12. 46. Plowman SA, Smith DL [1997]. Exercise 40. NFPA [2007]. NFPA 1582: Standard on physiology: for health, fitness and comprehensive occupational medical performance. Boston, MA: Allyn and program for fire departments. Quincy, Bacon. MA: National Fire Protection Association. 47. Maniscalco P, Lane R, Welke M, Mitchell 41. Gibbons RJ, Balady GJ, Bricker JT, J, Husting L [1999]. Decreased rate of Chaitman BR, Fletcher GF, Froelicher VF, back injuries through a wellness program Mark DB, McCallister BD, Mooss AN, for offshore petroleum employees. J Occup O’Reilly MG, Winters WL Jr. [2002]. Environ Med 41:813-820. ACC/AHA 2002 guideline update for exercise testing: a report of the American 48. Stein AD, Shakour SK, Zuidema RA College of Cardiology/American Heart [2000]. Financial incentives, participation Association Task Force on Practice in employer sponsored health promotion, Guidelines (Committee on Exercise and changes in employee health and Testing). productivity: HealthPlus health quotient [http://content.onlinejacc.org/cgi/content/s program. J Occup Environ Med 42:1148­ hort/40/8/1531]. 1155.

49. Aldana SG [2001]. Financial impact of 42. IAFF, IAFC [2000]. The fire service joint labor management wellness/fitness health promotion programs: a initiative. Washington, DC: International comprehensive review of the literature. Association of Fire Fighters, International Am J Health Promot 15:296-320. Association of Fire Chiefs. 50. Blevins JS, Bounds R, Armstrong E, Coast 43. NFPA [2002]. NFPA 1500: Standard on JR [2006]. Health and fitness fire department occupational safety and programming for fire fighters: does it health program. Quincy, MA: National produce results? Med Sci Sports Exerc Fire Protection Association. 38(5):S454.

51. Dempsey WL, Stevens SR, Snell CR 44. CFR. 29 CFR 1910.134, Respiratory [2002]. Changes in physical performance protection. Code of Federal Regulations. and medical measures following a Washington, DC: U.S. Government mandatory firefighter wellness program. Printing Office, Office of the Federal Med Sci Sports Exerc 34(5):S258. Register.

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52. Womack JW, Humbarger CD, Green JS, INVESTIGATOR INFORMATION Crouse SF [2005]. Coronary artery disease risk factors in firefighters: effectiveness of This investigation was conducted by and the a one-year voluntary health and wellness report written by: program. Med Sci Sports Exerc 37(5):S385. Tommy N. Baldwin, MS Safety and Occupational Health Specialist 53. Stevens SR, Dempsey WL, Snell CR [2002]. The reduction of occupational Mr. Baldwin, a National Association of Fire absenteeism following two years of Investigators (NAFI) Certified Fire and firefighter wellness program. Med Sci Explosion Investigator, an International Fire Sports Exerc 34(5):S194. Service Accreditation Congress (IFSAC) Certified Fire Officer I, a Kentucky Certified 54. Unpublished data [1997]. City Auditor, Fire Fighter and Emergency Medical City of Phoenix, AZ. Disability retirement Technician (EMT), and a former Fire Chief, is program evaluation. January 28, 1997. with the NIOSH Fire Fighter Fatality Investigation and Prevention Program, Cardiovascular Disease Component located in Cincinnati, Ohio.

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