for First Arriving Network
A recent survey of 2,400 firefighters contributes to the renewed national conversation on firefighter health and efforts to prevent line of duty deaths from cardiovascular and other health events.
This conversation is critical given that 2014 is proving to be one of the worst years for firefighters killed by stress, overexertion or heart attack. The year has already seen 57 line of duty fatalities as of August 27, with 32 of these due to stress/overexertion, and 29 of those specified as heart attack. That’s 50.9% of all LODDs this year attributed to a heart attack.
The survey by the First Arriving Network found the majority of respondents support annual physicals; have received one within three years; value input from their physicians; and support ongoing departmental fitness Yet, 35% of respondents said they currently have a medical condition that might limit them on the fire/rescue scene.
Even more disturbing: nearly 18% said they would likely disregard medical advice to temporarily or permanently stop firefighting due to a health issue, answering that they would “Keep being a firefighter, we only live once.”
It’s a startling red flag that 18% of respondents would disregard the impact of their own health on their crew and the victims they serve. Only 23% would follow their doctor’s advice immediately, while another 32% said they would base what they do on how they feel.
“That’s cultural, behavioral, and part of the psyche of the fire service, and it’s finally being challenged,” says Chief Ron Siarnicki, Executive Director of the National Fallen Firefighters Foundation. “It is concerning, but is it surprising? Probably not.”
Siarnicki points to studies that show some firefighters who suffer cardiovascular events were known to have preexisting conditions, by themselves and their supervisors, and nothing was done about it.
“That’s one of the problems related to behavior and we’re trying to do something about it,” he says. “The truth of the matter is — I’d rather you be healthy and not on a hose line than see your name placed on a memorial.”
These troubling responses back the concept that firefighters at risk should be identified and counseled to take appropriate measures to avoid suffering a cardiovascular event, as concluded in two recent studies by the CDC and the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease.
The Issue of Medical Advice
The author of the CDC study offers her personal opinion regarding firefighter health:
“It seems that every person has the right to choose to disregard medical advice and do what they feel is right for themselves and their families,” says R. Sue Day, Ph.D., associate professor of epidemiology at The University of Texas Health Science Center at Houston (UTHealth) School of Public Health.
However, in occupations that rely on teamwork to accomplish tasks where lives hang in the balance, it’s no longer a personal matter, she notes.
“The risk factors of someone else become your risk factors,” she says. “If one of the coworkers has chosen to disregard medical advice and put that risk on their colleagues, I’m not sure that’s a fair choice to make.”
National Volunteer Fire Council spokeswoman Kimberly Quiros explains the reasoning. “The culture of the fire service in the past has been to put others before yourself and put up a strong front even if something is wrong. There is also a fear being benched from service if they admit there is a health concern. We need to change this way of thinking,” she says.
“Firefighters need to know that their health comes first and they need to work on fixing that so they can best serve their department and community. It is not a sign of weakness to admit to medical limitations.”
A career survey respondent in Europe sums it up: “If you have health issues it’s your duty to report them; it’s not only your life on the line.”
The 2,400 First Arriving Network survey participants were mainly active firefighters, ranged from teens to age 65+, and were about half volunteer, half career and paid on call.
Does your primary doctor know you are a firefighter?
83.2% of the respondents answered Yes to this question, with the number for volunteers dipping to 77.4%, a number that remains encouraging. However, both could use improvement, says Day, who advocates an open line of communication between doctor and patient.
“I think a physician needs to be your confidant,” she says. “No one wants to get bad news from their doctor, but so many things now can be managed. You have to let people know your goals and what you’re trying to accomplish. Without information neither you nor your clinician can make good decisions.”
Does your department provide routine physical checkups?
- 48.3% overall said Yes. (Of those, 32.3% said the physicals were required, 16.0% said they were not required.)
- 45.3% said No.
- 4.4% said Don’t Know.
The survey saw a pronounced difference between responses from volunteer and career firefighters. After the initial pre-hire/join physical, 38% of volunteers and 67% of career firefighters said routine physicals are provided, with 22% and 51% being required.
Do you currently suffer from obesity, high blood pressure, heart issues or other health concerns that you feel might limit you physically on a working incident?
The responses to this question reveal grim data. Nearly 35% of all respondents, 833 people, said they were still active in the fire service despite suffering from obesity, high blood pressure, heart issues or other health concerns that they admit could limit them physically when working on an incident.
“Unfortunately, it’s societal,” Siarnicki notes. “It doesn’t matter if you’re a firefighter or a cop or a teacher… we say, ‘Those things don’t happen to us.’”
He says the NFFF is trying to address this from a prevention standpoint like the TSA: “If you see something, say something,” he says. “If a firefighter isn’t well, instead of just sending them home, put them on a heart monitor. At least get a read. If it’s not a heart attack, in the worst case, you’ve wasted five minutes and practiced with the medical equipment—or, you catch a heart attack in an early stage when it can be fixed.”
- Only 60.9% of the respondents said No or Don’t Know to having a health concern
- Another 4.4% (105 people) said Yes, But I’m Not Active.
- Of the total 938 people who said Yes, why are 89% of them still active? We know it isn’t just a matter of money.
- Of the career firefighters who answered Yes, 85% reported still being active. Of the volunteers who answered Yes, an even higher 91% remain active.
Unlike paid/career firefighters whose livelihoods depend on their paychecks, volunteer firefighters could presumably sideline their firefighting while continuing the “day jobs” they depend upon.
The survey suggests age as a factor, with younger respondents possibly considering themselves at lower risk. Of those 24 and under, 22.4% said they have a health concern, and over 95% of those respondents said they are still active.
The medical community is partly at fault for this, according to Day’s CDC study, which found there is a lack of health counseling to young firefighters.
“The real take-home of the study is that the physicians that are providing the counseling are not giving the advice to the younger firefighters, who have the longest future ahead of them and most opportunity to have further decline in their health,” she says. “If firefighters are not being told when they’re young it’s a missed opportunity. Their physicians need to let them know there are risks and things that can be done.”
When was your last physical exam?
More than 90% of those 35 and over reported having one in the last 3 years—which is good, if they follow the advice they receive. The survey did not ask about the extent of the exam, so these could range from a 10-minute annual checkup to a full work-up. Among volunteers, 87% reported a physical within the last 3 years, while among career firefighters it was nearly 95%.
If you are over 40, have you had a heart test (EKG at minimum) and blood work done in the last 2 years?
This question revealed a staggering difference between volunteer and career responses. Of the volunteers, just 30.6% said Yes, while of the career firefighters, 80.6% said Yes.
“This is concerning,” Quiros says. “We need to continue to work to educate volunteers on the importance of getting recommended health screenings and their responsibility to themselves and their department to participate in these screenings. We also need to make sure the volunteers have access to these screenings, either through their department, a community group or hospital, or their health insurance.”
“All firefighters need regular medical monitoring,” Day agrees. “There’s research right now funded by FEMA looking at what tests and at what time. In the meantime, NFPA 1582 is the best place to start.”
Do you think all fire departments should provide annual physicals?
A whopping 93% of respondents said Yes to annual physicals; among volunteers it was 89% and among career firefighters it was 97%.
“Physicals…get them,” writes one volunteer survey respondent from Massachusetts. “I’ve seen several lives saved because of annual physicals.”
This firefighter buy-in for physicals offers a positive note among the survey’s darker revelations.
Day says those in research want to see all firefighters get physicals relevant to their occupation by physicians trained to understand their specific risks and requirements.
“Knowing your numbers and receiving a doctor’s advice are critical to a firefighter’s health,” Quiros adds. “It is encouraging that firefighters understand the importance of health screenings.”
She notes that departments that can’t afford to provide health screenings can work with local hospitals, doctors, medical schools, or Medical Reserve Corps teams to donate their services.
However, some in the fire service retain hesitation about physicals. “Yes a yearly physical should be standard, but all too many times it becomes punitive, which meets with hostility from firefighters,” writes a career respondent from Ohio. “…Remove the punitive part, allow for better health care and preventative Tx. Embrace a healthy lifestyle from the top down. Then see what changes for the better.”
Does your department REQUIRE a physical prior to joining or being hired in an operational role?
Key Stat: 70.6% said Yes.
It’s no surprise that among volunteers, 50.1% said No and 49.9% said Yes—meaning half the nation’s volunteers may not be receiving even the most basic physical exam before becoming a firefighter. As evidenced by national line of duty death statistics, this needs to change.
On the opposite end of the spectrum, 92.7% of career firefighters responded that a physical was required.
Should there be minimum physical fitness & health requirements for firefighters to remain operational (after being hired/joining)?
Key Stat: 91.6% said Yes. Of those, 58.9% selected “Yes AND reviewed every year,” while 32.8% selected “Yes AND reviewed every few years.”
Among career respondents, 69.7% selected Yes and annually, while 24.7% said Yes and every few years. Only 5.6% said No, not after initial. Among volunteer respondents only 49.3% supported annual requirements, but an increased 39.2% said Yes to every few years. The number who said No increased to 11.5%. These numbers indicate that volunteers are seeking a little more flexibility than career firefighters, but most are similarly open to physical requirements.
“It is very encouraging that firefighters are recognizing the importance of meeting health requirements and seem to understand that being healthy and fit for the job is a key responsibility of a firefighter,” Quiros says.
“Firefighters should have unlimited sick leave and paid medical insurance,” suggests a career respondent in Australia. “They are paid for what they are prepared to do every time they roll out the door. Their skills and abilities should be maintained and assessed every year or so and ongoing professional development is a must. Maintaining a firefighter’s operational capability is a joint responsibility from the department and the individual.”
Would you ask a doctor, if given a health diagnosis, if you should continue being an active firefighter?
Interestingly, this hypothetical question is one of few where both career and volunteer firefighters responded nearly identically.
- 72.9% of all respondents said they would tell the doctor they are a firefighter and ask how that impacts their condition.
- 13.1% said they wouldn’t ask because they’d make their own determination.
- 9.9% said they wouldn’t ask because they wouldn’t want a doctor telling them they can’t be a firefighter.
- 4.1% said they don’t know what they would do.
- 72.2% of volunteers said they would tell a doctor, in line with the 73.9% of career respondents and the overall average, regardless of age or status.
- 12.6% of volunteers wouldn’t ask, and would make their own decision; the differences for career respondents were less than 2%.
- 10.7% of volunteers wouldn’t ask because they wouldn’t want a doctor telling then they couldn’t be a firefighter; these differences for career respondents were also less than 2%.
- 4.5% of volunteers didn’t know, compared to 4% of career respondents.
If a doctor told you to “scale back” your physical activity due to a health issue (i.e. stop being a firefighter for a time being or permanently), would you likely …
This is another hypothetical question that may or may not reflect how respondents would react in the real world, but the responses hint at a potentially reckless mentality among a portion of the firefighting population.
- 32% would base their decision on how they feel.
- 27.2% would ask their department officer/Chief for advice. (While these officials are not doctors, they could provide valuable input on how the decision would impact the firefighter’s pension, etc.)
- 23.3% would follow the doctor’s advice immediately.
- 17.5% would “Keep being a firefighter, we only live once.”
Siarnicki suggests part of the issue is that there isn’t a concrete, one-size-fits-all indicator for cardiac death, leaving risk levels somewhat open to interpretation.
“The difficulty is for some people, the science isn’t there yet. We’re on the verge of that,” he says.
- Volunteer Responses: 29.4% would base what they do on how they feel. (This number is fairly consistent by age group and type, almost all of which fall within a few percentage points of the 30% range. That number grew to 35.2% for career firefighters, which could be explained by the risk of ‘losing’ their careers and experiencing a financial impact from their department’s pension and disability plans.) Only 24% would follow a doctor’s advice immediately. (Of those age 24 and under, only 10.9% would do so. However, the number jumps to 31.3% for firefighters over 35, an unsurprising swing.
- Career Responses: There wasn’t much difference from career respondents, of which 23.2% said they would follow a doctor’s advice. 27.5% would talk to their department officer about what to do. 19% would “Keep being a firefighter, we only live once.” (It’s not surprising the number shoots up to 25.3% for firefighters age 24 or younger, who are less likely to be impacted by family concerns. Still, even in the 35 and older group, 14% would keep firefighting. This number wasn’t as low as one might expect for career firefighters: 16.5% said the same.)
NVFC Deputy Director Sarah Lee suggests readers consider causal factors for some of these responses. “For example, career firefighters are more likely to have short/long term medical disability coverage and/or light duty options, or even retirement options, which may incentivize them to take some time off—whereas the volunteer alternative may be to simply stop volunteering,” she notes.
Of the 160 respondents who answered this question with the carefree attitude, 97% said they suffered from something that may limit them on the fireground. They were also less likely to tell their doctor they are a firefighter and ask if it impacted their condition (only 56.5% would compared to the overall average of 72.9%). 24% said they wouldn’t tell their doctor because they wouldn’t want the doctor telling them not to be a firefighter.
The survey did not offer an option for people to seek a second opinion with a medical professional.
Some of the survey respondents offered their views on this controversial stance.
“Physical fitness is important, and should be maintained. However a man should not give up his dreams because of a doctor’s recommendations,” writes a career firefighter in Texas.
“After being beat up on this job for 25 years, what else am I going to do for a paycheck? You can’t just stop doing the job,” writes another career firefighter in Washington.
Some respondents took the opposite position:
“If you think you can be unhealthy and function well as a firefighter you’re lying to yourself. You’re putting yourself in danger, your brothers in danger, and endangering your community,” writes a career firefighter in Kentucky.
“As an overweight firefighter/paramedic I feel we really need to pay attention to what the docs are telling us. I refused to listen for too long and it got me to a spot where I was removed from firefighter for about 7 months. I lost over 100lbs, but I should have never gotten that bad. I could’ve seriously injured myself, or worse, my brothers and sisters… If your doc tells you to work on your weight, don’t brush it off, WORK it off,” writes a volunteer in Alaska.
About the Survey
The responses came from around the world, but primarily the United States. They generally lined up with where the most firefighters are located, with the top five states being New York, Pennsylvania, Texas, Ohio and Michigan.
Line of Duty Death Stats
The USFA, which tracks firefighter fatalities and provides an annual report, lists heart attacks as the overall leading fatal injury, responsible for 47.2% of line of duty deaths.
In the USFA’s most recent annual report, detailing 2012, data again shows heart attacks as the most frequent cause of death, claiming 39 of 81 firefighters that year, or 48.1%.
For 2014, the numbers continue in this trend with 50.9% of all the LODDs reported so far this year attributed to a heart attack as of September 1st.
If these numbers hold, 2014 will be one of the deadliest years in the last 12 for this category, with 90.6% of all stress/overexertion LODDs attributed to a heart attack.
LODDs by Stress/Overexertion / Heart Attack
- 2014 – 56.1% (32) / 50.9% (29)
- 2013 – 32.1% (34) / 31.4% (33)
- 2012 – 55.4% (45) / 49.4% (40)
- 2011 – 58.6% (51) / 55.2% (48)
- 2010 – 61.4% (54) / 56.8% (50)
- 2009 – 53.8% (50) / 40.9% (38)
- 2008 – 43.8% (53) / 38.8% (47)
- 2007 – 47.1% (56) / 46.2% (55)
- 2006 – 50% (55) / 46.4% (51)
- 2005 – 51.3% (61) / 47.5% (57)
- 2004 – 57.3% (67) / 53% (62)
- 2003 – 47.4% (55) / 47.9% (56)
In 2013, the averages are slightly different due to an unusual number of multi-firefighter fatality incidents including those in West, Texas and Prescott, Arizona.
From 2003-2012, Stress/Overexertion accounted for 52% of LODDs, including 47.9% that were heart attacks. Those numbers seem to only be increasing, and they don’t discriminate between career or volunteer. 48.1% of all career LODDs from 2003-2012 were the result of stress/overexertion, with 42% of those specifically heart attacks. The numbers increased for volunteers, with 58% of LODDs due to stress/overexertion and 55% of those specifically heart attacks.
As a career survey respondent in South Carolina writes, “We should not be losing 50 plus brothers and sisters a year to issues that can be prevented. No excuse for it!”
Making Sense of the Contradictions
Perhaps there’s agreement that health requirements are good in theory, but hard to implement in reality.
With contradictory mentalities continuing to clash in the fire service, it will require ongoing effort to overcome the obstacles toward prioritizing health—whether they are a matter of the mind or of limitations to budget, staffing, etc.
“It’s going to take behavioral modification and culture change to make it happen,” Siarnicki says.
In addition, of course, “Medical standards have a price tag to them,” he acknowledges. “There is a huge dilemma out there; we know physicals will catch some things, but there’s no funding source to make these changes happen. It’s a matter of cost vs. availability of funds and a decision on acceptable level of risk.”
The NFFF is currently working toward medical and behavioral research through partnerships with several organizations, including Johns Hopkins, the Harvard School of Medicine, Skidmore College, Drexel University and the Medical University of South Carolina. The organization is also looking toward the possibility of apps for firefighters to use for self-assessment and assessment of their peers.
The NVFC also is looking at the connection between physical health and behavioral health.
“Health and safety for our firefighters cannot be underestimated,” Quiros says. “Departments should do everything they can to overcome the challenges and meet health standards.”
She suggests that even if departments have to work gradually to meet the recommended standards, they should continue striving for that goal. The NVFC worked with the NFPA to produce a guide to help volunteer departments understand and meet NFPA 1500, accessible from http://www.nvfc.org/hot-topics/nfpa-standards.
Quiros also points firefighters toward their Heart-Healthy Firefighter Program and resources at www.healthy-firefighter.org, as well as a new program called Shared the Load, which focuses on admitting behavioral health issues and seeking help. “The goal is to break the stigma of behavioral health in the fire service,” she says.
“We need to continue to promote health in the fire service at the national, state, and local levels. Department leaders need to emphasize the importance of good health and regular screenings to their members, and to lead by example.”
- Comments about Firefighter Health from Survey Participants
- CDC: More than 70% of Firefighters Overweight, Obese
- Hopkins Study Targets At-Risk Firefighters to Prevent Cardiac Events
Overview of Respondents
- 89.3% are Active Firefighters and 6.2% are Retired. The remaining respondents are either not active in operations, are civilians, or “other.” Not operationally active and retired firefighters were excluded from most results.
- 48% are Volunteer, 39.4% are Career and 9.7% are Paid on Call.
- 28.2% are 25-34 (25.8% for Volunteers)
- 22.9% are 35-44 (18.2% Volunteer)
- 19.8% are 18-24 (26.9% Volunteer)
- 17.7% are 45-54 (16.3% Volunteer)
- 7.7% are 55-64 (7.5% Volunteer)
- 1.9% are Under 18 (2.6% Under 18 Volunteer)
- 1.7% are 65 or Older (1.6% Volunteer)
To put this in context, 50% of the overall respondents are 35 and over.
Of volunteer respondents, 43.6% are 35 and over; of career respondents, 60.8% are 35 and over.
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