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 Hemopericardium – 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 cardiovascular disease 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 death 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 Pre ven tion recommendations to reduce the risk of on-the-job Program is conducted by the National Institute for heart attacks and sudden cardiac arrest 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 deaths 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). Page 2 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 The Captain arrived at the local ED at 2137 hours. pericardial effusion was noted during the scan Initial impression in the ED was chest pain related and a widening upper mediastinum was noticed to myocardial infarction (MI), otherwise known on the chest x-ray. The Captain was transferred as a heart attack. An electrocardiogram (EKG) to the medical intensive care unit 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 coronary artery disease, 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 pericardium 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 aorta 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.