Wednesday, December 11, 2019

Firefighters and Coronary Heart Disease: A Brief History on Research and Analysis

From Fire Engineering, Dec 6 2019

By Aditya Shekhar

Whether we want to admit it or not, firefighting and emergency services in general can be a dangerous profession. On firegrounds, there are hazardous materials, flames, heavy machinery, and potentially insecure structures. Responding to emergencies, especially with lights and sirens, dramatically increases the likelihood of traffic accidents. The stress of firefighting and the memories of certain calls can leave permanent scars in the form of post-traumatic stress disorder and other forms of mental illness. However, there is one risk that doesn’t receive as much coverage in the firefighting world: heart disease.

Data from the National Fire Protection Association found that, of the 60 firefighter fatalities that occurred in 2017, 29 were because of sudden cardiac death. Firefighters, as an occupation, have some of the highest rates of heart disease, heart attacks, and sudden cardiac death. There have been several studies published examining firefighters’ unique risk profile and the epidemiology of heart disease in the fire service.


Surviving the Fire Service Cardiac Epidemic

FLAME Out: Cardiovascular Risk on the Fireground

Fitness: Cardiovascular Training for Firefighters

One of the first studies of the hearts of firefighters was published in 1975 by R.J. Barnard and H.W. Duncan in the Journal of Occupational Medicine. They looked at the heart rates of firefighters responding to emergencies and when engaged in firefighting. Less than a minute after the tones dropped, they recorded an average increase in heart rate of 47 beats per minute. During actual firefighting, researchers recorded unusually prolonged periods of tachycardia. They concluded that firefighting creates states of high anxiety, which then leads to tachycardia.

An early study looking at the relationship between firefighting and heart disease was published in the American Journal of Public Health in 1992 by Dr. James Friel and Dr. Michael Stones. After interviewing 200 Canadian firefighters in 1987 and 1988, they found high levels of obesity and high cholesterol, each being significant risk factors for heart disease. However, these are also modifiable risk factors, meaning that they can be changed with lifestyle modification or pharmacological therapy.

A few years later, Glueck and colleagues published a study in the American Journal of Industrial Medicine (1996). Beginning in 1984, they recruited 806 firefighters without coronary heart disease (CHD). They followed each firefighter for an average of 6.4 years and looked at participants’ weight, blood pressure, fasting glucose, and lipid profile, among other risk factors for CHD. If a participant was found to have high levels of risk, they were advised on how to reduce their risk, given an Electroencephalogram stress test and a thallium scan. Over the course of the study, seven men had heart attacks and 15 developed coronary heart disease. These 22 men were more likely to be smokers, have a family history of heart disease, have higher blood pressures, have higher low-density lipoproteins (LDLs) and total cholesterols, and higher triglycerides. That being said, the CHD rate found by the study was lower than a comparable nonfirefighting population. Researchers concluded that most of the participants’ risk stemmed from modifiable lifestyle choices. (It’s worth noting that this study specifically recruited participants without any heart disease at the outset and from one department only, which presents a selection bias.)

One of the most prominent researchers on the link between firefighting and heart disease is Dr. Stefanos Kales of Harvard’s T.H. Chan School of Public Health. A 2003 study conducting by Kales and several colleagues published in Environmental Health looked at the CHD-related deaths of 52 male firefighters to better understand what sorts of activities precipitated their fatal cardiac events and whether certain fire department duties might be more likely to lead to CHD-related death.

In their background research, they found that, from 1977 to 2002, CHD accounted for 45 percent of on-duty deaths. For reference, CHD was attributed to just 22 percent of on-duty deaths among police and detectives and 11 percent of emergency medical services (EMS) providers. Although the disease may be underlying, researchers also found that specific duties were likely to trigger a CHD-related death. For instance, they noted that actual suppression accounts for less than two percent of a firefighter’s duties but up to 36 percent of deaths. Responding to emergencies also increased the risk of a CHD-related death five-fold. Interestingly, only six percent of CHD-related deaths came during EMS runs (even though EMS calls represent most of the calls for many departments). Unfortunately, most firefighters who experienced CHD-related fatalities had not undergone a fire department medical exam within the previous two years.

Kales also examined a larger sample of firefighter deaths in a 2005 study published in the New England Journal of Medicine. He looked at the Federal Emergency Management Agency’s data on all firefighter deaths from 1994 to 2004 (excluding deaths because of the 9/11 attacks) and examined the ones that were found to be CHD-related. His research showed that 32.1 percent of deaths occurred during fire suppression, 17.4 percent occurred during returning from an alarm, 15.4 percent occurred during nonemergency duties, 13.4 percent occurred during responding to an alarm, and 9.4 percent occurred during responding to nonfire emergencies. Considering the time firefighters spend performing these duties, Kales found that the risk of a CHD-related death was up to 136 times higher during suppression, 14.1 times higher during alarm response, 10.5 times higher during alarm returning, and up to 6.6 times higher during physical training.

Looking at the statistics regarding firefighter mortality, it’s clear that heart disease and sudden cardiac death account for an overwhelming number of on-duty firefighter deaths, far eclipsing any other means. The literature on firefighters and heart disease seems to suggest that there is an inherent risk to being a firefighter and aggravating coronary heart disease. The stress of firefighting, shift life, and the body’s physiological response creates extended periods of tachycardia and other unusual patterns of heart load that aren’t found in a general population. There’s also something unique about the activity fire suppression that creates significant risk. The reason behind this extreme increase is currently unknown.

Departments and individuals can mitigate their risk of suffering a CHD-related death by reducing or eliminating their modifiable risk factors including smoking, obesity, high blood pressure, and high LDL cholesterol. Departments can encourage better nutrition through healthier meals and smaller portions, institute science-based and heart-healthy exercise regimens, and install stricter requirements on medical examinations and early screening for heart disease. Firefighting is an incredible profession for incredible people. If we work together, we can extinguish the risk of CHD.

(Photo by U.S. Air National Guard Airman 1st Class Cody Witsaman.)


Fahy RF, PR LeBlanc, JL Molis. “Firefighter fatalities in the United States in 2017.” NFPA Journal. July 2nd, 2018. Retrieved from

Barnard RJ and HW Duncan. “Heart rate and ECG responses of fire fighters.” Journal of Occupational Medicine. 1975 Apr;17(4):247-50.

Friel JK and M Stones. “Firefighters and heart disease.” American Journal of Public Health Aug. 1992.

Glueck CJ, W Kelley, P Want, et al. “Risk factors for coronary heart disease among firefighters in Cincinnati.” American Journal of Industrial Medicine. Sept. 1996.

Kales SN, ES Soteriades, SG Christoudias, et al. “Firefighters and on-duty deaths from coronary heart disease: a case control study”. Environmental Health. Vo 2, No. 14 (2003).

Kales SN, ES Soteriades, CA Christophi, et al. “Emergency Duties and Deaths from Heart Disease among Firefighters in the United States”. N Engl J Med 2007; 356:1207-1215 DOI: 10.1056/NEJMoa060357

Aditya Shekhar is a research scientist, EMS educator, and writer. His articles about the physiologic progression of heart attacks have been read globally and won awards in the field of cardiology. He has taught Paramedic, EMT, EMR, and CPR courses in the United States and internationally and has designed online educational content for EMS providers.

Wednesday, December 4, 2019

Excellence on Fire

What US Corporations Can Learn from the American Fire Service

Ben May

I can think of no more stirring symbol of man’s humanity to man than a fire engine.
Kurt Vonnegut

‘In a fire you can plan everything out to the minute, and a minute after that...everything changes.’
Dan Felix, Division Chief, San Jacinto California Ranger District

The Most Trusted Brand in America

Imagine a professional organization, driven by a tradition and an active, living mission of excellence, poised for service delivery 24/7. Now, think of a brand so pervasive that it is in every neighborhood in this country almost four times more ubiquitous than Starbucks. *

Consider that this organization has no market segmentation because every customer in the nation receives the highest quality of service based on one phone call day or night. Now picture an organization’s corporate brand so well-known and popular that its physical shape is immediately recognizable and understood; that the brand evokes such trust that the men and women representing it are consistently co-opted for any number of commercial products advertised in the media, hoping to grasp just a tiny piece of its halo effect, the brand being so pervasive that children play with toys representing it, dressing up in costumes of the men and women who engage in its work, many aspiring to ‘be one when he/she grows up.’ Consider that this brand has so much equity and confidence that Americans trust the organization second only to their families. * It’s no surprise that it’s the American Fire Service. Walk into the local firehouse, and you begin to understand. As you walk past the shiny, immaculately clean apparatus you are greeted by smiles and a searching look that signifies a sincere desire to help. You are seeing the personification of true customer service. This is a mission-driven philosophy that works because its very existence is based on continuous improvement for the protection of the life and property of every community in our country.
The Philosophy of ‘No Choice: The High Ground of Leadership

There are no lack of philosophies and prescriptions from corporate, non-profit and military leaders, scholars, practitioners and theorists about how organizations, especially corporations and businesses, should be run to better serve their customers and members. Whether it’s the’ knowledge worker’ management philosophies of Peter Drucker, W. Edwards Deming’s Total Quality Management or Motorola’s Six Sigma, it seems there are more ideas, observations and strategies than there are companies and organizations to implement them. Regardless of mission, vision and ‘triple bottom line,’ corporations exist for one underlying goal: profit. Certainly, that is as it should be to contribute to our national economy. Creating and maintaining customers are the lifeblood of the enterprise. CEOs and executives lead their organizations to fulfill the corporate mission: a profitable mission. Not so for public service; certainly not the fire service.

Leadership in the fire service is on a vastly different plane than that of corporations. Leadership is the organization’s life source. Fire officers operate from a unique set of principles. Their mission is driven from the heart. There is no profit motive. Firefighters carry, maintain and extend the necessity of high-touch in, for many, a disinterested, impersonal, high- tech society. They bring the flame of immediate compassion in action. There is no choice or compromise in the fire service’s mission: leadership and service excellence are bred into the organization at every level, from firefighter to fire chief. Every member is a leader from the day he or she takes the oath. Leadership is the central practice of career-long professional development in the fire and emergency services. There is no choice but to seek the highest standards possible: a constant for each firefighter and officer... Consider a mission of no choice. There is a saying in Israel about that country’s origin and place in a constantly hostile neighborhood: ‘en brera:’ ‘No choice.’ It’s no wonder that the necessity of ‘no choice’ has made Israel one of the most innovative countries in the world. It is the same with the fire service. Regardless of the situation, whether a medical emergency, wildfire inferno or the tragedy of 9/11, no choice but to achieve excellence to fulfill the mission of one of the most noble callings on earth: protecting lives and property. Think of how this concept can be transferred to a corporation or organization. It may not be an emergency service, but think how any enterprise-business, non-profit or government service- could gain such clarity and focus for every member of the organization with the courage to imagine a better future for your product or service and to follow through on your conviction as if lives depended on it; certainly, in many industries they do.
‘First Right’

Firefighters protect our citizens' first right as written in the Constitution: 'life,' so that we can enjoy the other two, 'liberty and the pursuit of happiness.' The history of this country is intertwined with firefighters. It is no coincidence that Ben Franklin founded the first fire department in America, Union Fire Co. in Philadelphia, or that the first five presidents of the U.S. were volunteer firefighters.

Firefighters love being firefighters. Most of the hundreds I have known always wanted to be firefighters since they were small children. I remember a young lieutenant who told me during a difficult time in our department that the only real regret he had in his life was that he could not live two lives so that he could be a 0firefighter twice. Many of the 1.5 million firefighters in this country are paid firefighters in one jurisdiction and volunteers in another one close by. The reason for this is because they love what they do so much.
Who Becomes a Fire Service Leader?

Who are these people? They are not so much your blue-collar workers as in the past. Most now have college degrees at the minimum, with a growing number receiving advanced degrees with career-long education in leadership and any number of technical and scientific subjects. An individual doesn't become a firefighter by accident or on a whim. There can easily be as many as 200 applicants for every available position in a metropolitan department. All-night vigils to apply to take the examination are not unusual. If one does pass the entrance exam, it is not unusual to be on a waiting list, sometimes, for a few years. Firefighting has become a diverse profession, with many women, African and Hispanic Americans in leadership positions; many as fire chief in major cities in the US. Passing this battery of tests allows a successful applicant to become a 'rookie,' which has its own complex curriculum. After that, it's constant training and study for the rest of one's career. The result is an extremely intelligent individual in superb physical condition responsible for our citizens' safety day and night. This is especially true for senior fire officers and chiefs. Some of this country's finest leaders are fire chiefs and fire administrators bedecked with any number of advanced degrees. Most receive a master’s degree in Public Administration, Chemistry, Engineering, Emergency Management or Business. Many receive the much sought-after Chief Fire Officer designation from the Center for Excellence in Public Safety, the organization that accredits fire departments and credentials fire officers across the nation. Being a leader in public safety in a metropolitan fire and emergency services department is every bit as challenging as that of a CEO in private enterprise. Leaders in local public service are under constant scrutiny from a wide range of constituents, living in a fishbowl day and night. There is no room for ‘adequate’ leadership in the fire service. No ‘market segmentation’ for emergency service means every citizen in this country receives the highest quality service whether living in an elegant apartment building or mansion in the suburbs or in a cardboard box under a bridge.
A Pinnacle of Brand Equity in Creative Action

Any good corporate marketing officer knows that trust is the key criterion of brand development. Study any marketing text of the attributes of an irresistible brand and you will find every box with a check for the fire service. Brand trust and relevancy do not just appear in the marketplace. It is earned through millions of actions and certainly interactions-some large and some small-everyday. In the case of the fire service it is around the clock in every city and neighborhood; in every wilderness area where wildfire threatens. These expectations are the result of strategies each fire department develops and modifies based on potential hazards in the community. There is no one size fits all. Every jurisdiction has its own risk characteristics. This kind of responsibility requires a kind of dedication, intelligence and leadership that any corporation and business can learn to emulate. The US Fire Service is replete with such lessons. The very nature of emergency services demands strategies and tactics designed for the challenges of rapidly changing situations. These ‘strategies’ are based on very short timelines. This is a concept known as ‘incident command.’ Think of a strategic plan in which the tactics are changing minute to minute, or customer service in which the client’s worst day is met by professionals whose quality of actions represent their best day, especially and individually for you. And every situation is as different as the ‘customer’ they serve. Training for these professionals is so critical because ‘unknown’ is the nature of the business. Most of the training in the fire service is, by definition, instinctual or second nature. This allows for the creativity and innovation so necessary when facing mostly unexpected, dangerous situations. However, there is a rapidly growing number of the most necessary and heart-rending situations that are not emergencies. I have seen many calls for service from emotionally disturbed people who literally needed to see that someone just cared in our ever- growing, alienated society. The Lebanese philosopher, Kahlil Gibran wrote that ‘work is love made visible.’ Surely, the fire service is one of the purest forms of this philosophy.
The Global Landscape for Courageous, Intelligent Leadership in a Changing World

The fire service has continued to grow as the market for its services has expanded. Originally developed as a reactive agency for fire emergencies, the fire service has broadened to fulfill the needs of its ‘markets,’ whether its emergency medical services for an aging population, the opioid epidemic, increased severe weather destruction, the perilous growth of wildfires in the wildland urban interface, or now, sadly, live shooter situations. According to the National Fire Protection Association, in 2017 every 24 seconds a fire department responded to a fire somewhere in the United States. Fire departments responded to 26,880, 800 incident calls according to the US Fire Administration in that same year, 64% of those calls were emergency medical with 4% fire related. However, many buildings and houses are now composed of materials that burn faster and hotter. There were still 1, 319, 500 fires in the US in 2017 with 3,400 deaths and 14,670 injuries with $23B in property loss. These are only direct costs. Wildfires alone accounted for $8B. The United States still very much has a ‘fire problem,’ especially compared to other first world countries. Most people would agree that when they turn on the local news or scan their favorite media source, there is usually a story about a house fire sometimes daily, but certainly weekly. This is not the norm in other Western countries. The growing number of fast- burning materials in new home construction are carcinogenic, leading to an uptick in cancer- related diseases for firefighters and less time for people to leave a burning building. Confronting these problems has led to a much more granular analysis of local hazards through detailed data analysis, initiating proactive risk reduction programs expanding across the country. In 2018 there were 1, 216, 600 fire fighters serving in 27, 228 fire departments nationwide responding to emergencies from 51,150 fire stations. Only 31% (346,150) of the fire fighting force are career with 788,250 volunteers. Considering return on investment, the fire service continues to grow its value in the community. Through inspections and quick response fire departments save many businesses, many of them small businesses: the lifeblood of small communities.
Today’s Challenges for the Fire Service

While there are philosophies and strategies corporate America can learn from the leaders of our nation’s fire officers, they can also learn from how the fire service faces its own challenges. “300 years of tradition unimpeded by progress” is a slogan the fire service dropped years ago but the fact that it even existed demonstrates the constant need for the fire service to challenge and eliminate those practices and traditions that are no longer useful in a rapidly changing environment-physically and socially. It’s a matter of corporate culture and how the fire service embraces the challenges of changing needs from the changing populations they serve. Possessing the best people for a service most communities love does not guarantee that the fire service will continue to operate as it has in the present time of turbulent change. Rapidly changing technology in structures and building materials may dictate significant disruption. Innovative technologies may greatly diminish the need for firefighters to enter buildings presenting rapidly deteriorating conditions. While the mission remains the same, the strategies and tactics will change. Robotic firefighters have been in production for the last five years, with some models in experimentation now for the military. New commercial buildings must have sprinklers and smoke alarms, with new homes required to have smoke alarms. Presently only Maryland and California have laws that mandate new homes to have sprinklers. As the need for the ‘big red truck’ concept of firefighting is changing, the fire service will grow in its ability to be an all needs social service for the community. If the fire service does not adapt to change it faces the risk of losing pieces of its ‘business’ to private enterprise.

The good news is that, so far, the US Fire Service continues to transform itself quietly in line with its core mission to protect the life and property of every citizen day and night. In fact, the progression and expansion of the fire service exemplify a Blue Ocean Strategy of development. Created as a reactive, necessary service since before the founding of the Republic, it has expanded to a proactive, data-driven, all hazards agency replete with constantly modified preventative plans called Community Risk Reduction, involving multiple agencies modified to the needs of the communities they protect. This new approach to community protection matches risk to specific need through granular data mining, strengthening the fire service mission of an all hazards agency, as well as the creation of alliances with other agencies to serve the public.
Lessons from the Noble Calling

Considering the profusion of leadership lessons in the many handbooks, from every profession imaginable, consider these key points of difference from the fire service model to be useful for men and women leading organizations and companies.

1. Every Member a Leader

From the first day of rookie school, every firefighter is a leader. Think not? Consider a volunteer fire department where a building fire is reported in its area. Now, consider that the first person arriving at the station to drive the engine is not an officer, but a first-year firefighter. He or she is now responsible for driving the engine to the fire, assessing the situation, reporting status, checking for people hurt or trapped, getting water on the fire and establishing ‘incident command.’ Yes, this is an unusual situation. Aren't all emergencies? Leadership is built into the educational curriculum of the fire service. Every member studies it as a separate discipline for one’s entire career,, applying it in every aspect of the job. It is a fabric in the culture of the fire service
2. Pervasive Training and Education; Constant Preparation;
Perfecting the Basics

The necessity to remain calm in as many situations as possible demands training so pervasive that most actions and thoughts must be instinctual. This means constant preparation: perfecting the basics. Most calls require a ‘lessons learned’ meeting after returning to the station. This kind of instruction involves reacting to a plethora of unusual incidents, with no time wasted on trying to figure out what to do when confronted with the emergency. This does not just apply to emergencies. Fire officers are constantly creating and updating detailed ‘pre-fire plans’ which outline every action necessary should a particular building have an emergency. Fire prevention officers’ duties are to maintain commercial and institutional building safety through constant inspections, enforcement evaluation and public education. This kind of data driven analysis and preparation ensure creativity and innovation when confronted with unexpected, complex situations.

3. A Tradition of Heartfelt Care

One of the true points of difference between the fire service and other organizations is the strength of heart and personal care that define the spirit off each member. The idea of family is paramount. Being prepared to put one’s life on the line creates a very tight knit group of people. Consider that firefighters are really families caring for other families. Some years ago, there was a popular trend in the fire service that ‘customer service’ should be studied and applied to a public service just like other businesses. But the fire service is not a business. And this is the whole point. If any organization should be studied for excellence and process improvement, wouldn't it be instructive to consider the fire service, which by definition and necessity must improve its processes, especially when lives and safety are the heart of that process?
4. Facing Fear in the Line of Fire

There is a quote by Eleanor Roosevelt defining courage and poise, pursuing the need to face what one fears: “You gain strength, courage and confidence by every experience in which you really stop to look fear in the face. You must do what you fear.” On face value, one might assume that, of course, such advice makes sense for an emergency service. In fact, such an assumption is quite simplistic. Consider the words of Emerson that “most men lead lives of quiet desperation.'' This kind of courage comes from going beyond one’s comfort zone. Firefighters are constantly challenged to do just that but intelligently and with constant training and preparation. What reason could any manager or executive have not to go well beyond the comfort zone, to the dark side of ‘fear?’ Probably a risk worth taking for any of us in any organization. What could you achieve if you did what you were afraid to face?

5. Pride and Honor

When a firefighter is sworn in, the pride of becoming a member of such a respected organization instills a kind of nobility that imbues each member with a sense of such integrity that the word failure doesn’t recognize. Imagine this same sense of pride as you approach your career
6. Pursue Excellence ar Your Only Choice

There is a distinct difference in thought, strategy and execution when there is no choice but to succeed. Can you imagine if, by definition, your career depended on the need to perform flawlessly as though lives depended on it? If nothing else, the fire service teaches this ‘clarity’ of responsibility.
What about You and Your Organization and What about You?

Reflect, for a minute, on your position in the organization you represent. Can you say that its culture nurtures its members as part of a family on a mission of excellence to confront the fear of a future you can embrace every day? Do you swell with pride with the nobility of your company’s vision, strategies and actions? Walk into your local firehouse. Soak up the culture, intelligence and warmth of the place. Ask a few questions and see if you aren’t renewed by associating with some men and women whose answers reflect a mission of excellence on fire.

Personal Note from the Author

Since my first memory I always wanted to be a fire fighter. Throughout my career and life, I always felt that the privilege to be a part of the fire department was the ultimate pinnacle of my life. I have never wavered in that desire. After completing my professional career in the private sector I can honestly say that, for me, it couldn’t come close to the satisfaction I derive from those too few times I made my contribution to the fire service, just being around the fine men and women who wear the uniform. This article is dedicated to each of them. Ben May