Firefighter Safety and Health

Introduction
Every year, fires and other emergencies take thousands of lives and destroy property worth billions of dollars. Fire fighters help protect the public against these dangers by responding to fires and a variety of other emergencies. Although they put out fires, fire fighters more frequently respond to other emergencies. They are often the first emergency personnel at the scene of a traffic accident or medical emergency and may be called upon to treat injuries or perform other vital functions. (BLS)

Background
The United State's fire and emergency service reaches every community across the nation, covering urban, suburban and rural neighborhoods. Nearly 1.1 million men and women make up the fire service--293,600 career fire fighters and 784,700 volunteer fire fighters serve in 30,000 career, volunteer and combination fire departments across the United States. The fire service is the only entity that is locally situated, staffed, trained and equipped to respond to all types of emergencies. The fire department responds to natural disasters such as earthquakes, floods, tornadoes and hurricanes as well as to man-made catastrophes such as hazardous materials spills, arson and terrorism. As such, America's fire service is an all-hazard, all-risk response entity. (IAFC) Response activities that fire fighters are involved in include:
- Fire suppression:
- Emergency Medical Service (EMS)
- Hazardous Materials
- Code Enforcement
- Wildland Fire
- Wildland/Urban Interface
- Fire Prevention and Education
- Technical Rescue
- Urban Search and Rescue
- Aircraft Rescue and Fire Fighting
- Arson Investigation
- Federal and Military Fire Protection
- Explosive Response and Investigation
- Industrial Fire and Safety

Response Breakdown (2009)

Response Number % Change from 2008
Fires 1,348,500 -7.1
Medical Aid 17,104,000 +8.5
False Alarms 2,177,000 -2.9
Mutual Aid/Assistance 1,296,000 +6.7
Hazmat 397,000 +0.6
Other Hazardous (Arcing wires, bomb removal, etc.) 625,500 -10.3
All Other (Smoke scares, lock-outs, etc.) 3,586,500 +2.9
TOTAL 26,534,500 +5.1
Source: National Fire Protection Association reports Fire Loss in the United States 2009 and U.S. Fire Department Profile Through 2009

Fighting fires is complex and dangerous and requires organization and teamwork. At every emergency scene, fire fighters perform specific duties assigned by a superior officer. At fires, they connect hose lines to hydrants and operate a pump to send water to high-pressure hoses. Some carry hoses, climb ladders, and enter burning buildings--using systematic and careful procedures--to put out fires. At times, they may need to use tools to make their way through doors, walls, and debris, sometimes with the aid of information about a building's floor plan. Some find and rescue occupants who are unable to leave the building safely without assistance. They also provide emergency medical attention, ventilate smoke-filled areas and attempt to salvage the contents of buildings. Fire fighters' duties may change several times while the company is in action. Sometimes they remain at the site of a disaster for days at a time, rescuing trapped survivors, and assisting with medical treatment.

Fire fighters work in a variety of settings, including metropolitan areas, rural areas, airports, chemical plants and other industrial sites. They also have assumed a range of responsibilities, including providing emergency medical services. In fact, most calls to which fire fighters respond involve medical emergencies. In addition, some fire fighters work in hazardous materials units that are specially trained for the control, prevention, and cleanup of hazardous materials, such as oil spills or accidents involving the transport of chemicals.

Workers specializing in forest fires utilize methods and equipment different from those of other fire fighters. When fires break out, crews of fire fighters are brought in to suppress the blaze with heavy equipment and water hoses. Fighting forest fires, like fighting urban fires, is rigorous work. One of the most effective means of fighting a forest fire is creating fire lines--cutting down trees and digging out grass and all other combustible vegetation in the path of the fire in order to deprive it of fuel. Elite fire fighters called smoke jumpers parachute from airplanes to reach otherwise inaccessible areas.

Trends in Related Injuries and Fatalities
Fire fighters spend much of their time at fire stations, which are usually similar to dormitories. When an alarm sounds, fire fighters respond, regardless of the weather or hour. Fire fighting involves a high risk of death or injury. Common causes include floors caving in, walls toppling, traffic accidents, and exposure to flame and smoke. Fire fighters also may come into contact with poisonous, flammable, or explosive gases and chemicals and radioactive materials, all of which may have immediate or long-term effects on their health. For these reasons, firefighters must wear protective gear that can be very heavy and hot.

The most recent Topical Fire Report for Fire-Related Firefighter Injuries Reported to NFRS (National Fire Incident Reporting System) provides a good database for analyzing firefighter injuries.
• Between 2006 and 2008, an estimated 81,070 firefighter injuries occurred annually. Of this number, 39,715 occurred on the fire ground and 4,880 occurred while responding/returning from an incident.
• The majority of fire-related firefighter injuries (87 percent) occur in structure fires. In addition, on average, structure fires have more injuries per fire than non-structure fires.
• Thirty-eight percent of all fire-related firefighter injuries resulted in lost work time.
• Firefighter injury fires are more prevalent in July (10 percent) and peak between the hours of 2 and 5 p.m.
• Overexertion/Strain is the cause of 25 percent of fire-related firefighter injuries reported to NFIRS.

Sudden cardiac death represents the most common cause of a fire fighter fatality. In 2005, the National Fire Protection Association (NFPA) reported 44% (440/1006) of on-duty fire fighter fatalities during the ten-year period 1995-2004 were due to sudden cardiac death. (Fahy) Research by Kales et al (2003) concluded that "most on-duty CHD (cardiac heart disease) fatalities are work precipitated and occur in firefighters with underlying CHD." Improved fitness promotion, medical screening and medical management could prevent many of these premature deaths. The following table provides an overview of the number of on-duty deaths and injuries that occurred from 2000 to 2009 in the United States.

Firefighter Casualties 2000-2009 (USFA)
Year Deaths1 Fireground Injuries2 Total Injuries2
2000 105 43,065 84,550
2001 1053 41,395 82,250
2002 101 37,860 80,800
2003 113 38,045 78,750
2004 1194 36,880 75,840
2005 115 41,950 80,100
2006 107 44,210 83,400
2007 118 38,340 80,100
2008 118 36,595 79,700
2009 90 32,205 78,150
1 This figure reflects the number of deaths as published in USFA's annual report on firefighter fatalities. All totals are provisional and subject to change as further information about individual fatality incidents is presented to USFA.

2 This figure reflects the number of injuries as published in NFPA's annual report on firefighter injuries.

3 In 2001, an additional 341 FDNY firefighters, three fire safety directors, two FDNY paramedics, and one volunteer from Jericho (NY) Fire Department died in the line of duty at the World Trade Center on September 11.

4 The Hometown Heroes Survivors Benefit Act of 2003 has resulted in an approximate 10% increase to the total number of firefighter fatalities counted for the annual USFA report on Firefighter Fatalities in the United States beginning with CY2004. For more information, please see Reports and Statistics.

Furthermore, a U.S. Fire Administration report discussing fire-related firefighter injuries as reported to NFIRS shows that the primary cause of injury to firefighter at fire-related events from 2006 - 2008 as overexertion/strain (24.9%) followed by exposure to hazard (20%), contact with object (15.8%) and slip/fall (10%). The primary nature of the injuries during the same time period includes strains (23.5%), wound/bleeding (18.4%), burns (14%), other (12.6%) and dizziness/exhaustion/dehydration (12.6%). (U.S. Fire Administration)

In regards to the on-duty sudden cardiac deaths among firefighters investigated by the National Institute for Occupational Safety and Health (NIOSH), the following factors frequently were involved with the on-duty sudden cardiac deaths:
• Inadequate medical evaluations of candidates or members
• Insufficient work restrictions following the identification of specific medical conditions
• Absence of, or nonparticipation in, an adequate fitness or wellness program
• Delayed access to, or inadequate training on, automated external defibrillators (AED)
• The sudden death of the fire fighter while driving either a fire department vehicle or the fire fighter's personal vehicle while responding to an emergency incident

Costs
Based on a study commissioned by the National Institute of Standards and Technology (NIST), the actual costs of firefighter injuries and fatalities and the efforts to prevent them are estimated to be "$2.8 to $7.8 billion per year." (NIST) These costs are based on "workers' compensation payments and other insured medical expenses, including long-term care; lost productivity; administrative costs of insurance." These injury costs include psychological disorders as well, "especially if they require treatment." The League of Minnesota Cities (LMCIT) also reports that "firefighter work comp losses are some of the largest incurred in LMCIT's workers' compensation program" Furthermore, the League found that "firefighters have the third highest loss costs in the work comp program, comprising approximately 17 percent of total costs or approximately $2.4 million a year, on average" in Minnesota.

Barriers to Improvement
Work hours of fire fighters are longer and more varied than the hours of most other workers. Many fire fighters work about 50 hours a week, and sometimes they may work longer. In some agencies, fire fighters are on duty for 24 hours, then off for 48 hours, and receive an extra day off at intervals. In others, they work a day shift of 10 hours for 3 or 4 days, work a night shift of 14 hours for 3 or 4 nights, have 3 or 4 days off, and then repeat the cycle. In addition, fire fighters often work extra hours at fires and other emergencies and are regularly assigned to work on holidays. (BLS)

Another barrier to improvement is the current state of fitness and wellness programs for fire departments. The NIOSH on-duty fatality investigations from medically related cardiovascular disease from 1998 - 2005 found that only 41% of the departments had fitness programs, but that only 10% required participation. (DHHS) Key recommendations from this study indicated that fire departments should: 1) develop individualized fitness and wellness programs for all fire fighters, 2) conduct annual fitness evaluations and 3) include health promotion components such as smoking cessation, cancer screening, diet and nutritional education and immunizations. Resources are readily available from the International Association of Fire Fighters / International Association of Fire Chiefs and the National Volunteer Fire Council to assist departments in setting up simple programs to educate their members.

Prevention and Control Strategies
There are a number of prevention and control strategies within Haddon's Matrix that could be used to reduce the number of firefighter injuries and fatalities and are outlined in Appendix 1. The flowing paragraphs present additional details of some on-going programs within the fire service to improve firefighter safety. The National Fallen Firefighter Foundation (NFFF) is one organization. It is a non-profit organization devoted to honoring and remembering America's fallen fire fighters and assisting their families and coworkers. In 2004, the NFFF launched its Everyone Goes Home program to prevent fire fighter line-of-duty deaths and injuries. The program developed 16 life safety initiatives, which included, "develop and implement national medical and physical fitness standards that are equally applicable to all firefighters, based on the duties they are expected to perform." The program's Web site provides training materials for individual fire department to develop health and wellness programs. (NFFF) The 16 Firefighter Life Safety Initiatives include:
1. Define and advocate the need for a cultural change within the fire service relating to safety; incorporating leadership, management, supervision, accountability and personal responsibility.
2. Enhance the personal and organizational accountability for health and safety throughout the fire service.
3. Focus greater attention on the integration of risk management with incident management at all levels, including strategic, tactical, and planning responsibilities.
4. All firefighters must be empowered to stop unsafe practices.
5. Develop and implement national standards for training, qualifications, and certification (including regular recertification) that are equally applicable to all firefighters based on the duties they are expected to perform.
6. Develop and implement national medical and physical fitness standards that are equally applicable to all firefighters, based on the duties they are expected to perform.
7. Create a national research agenda and data collection system that relates to the initiatives.
8. Utilize available technology wherever it can produce higher levels of health and safety.
9. Thoroughly investigate all firefighter fatalities, injuries, and near-misses.
10. Grant programs should support the implementation of safe practices and/or mandate safe practices as an eligibility requirement.
11. National standards for emergency response policies and procedures should be developed and championed.
12. National protocols for response to violent incidents should be developed and championed.
13. Firefighters and their families must have access to counseling and psychological support.
14. Public education must receive more resources and be championed as a critical fire and life safety program.
15. Advocacy must be strengthened for the enforcement of codes and the installation of home fire sprinklers.
16. Safety must be a primary consideration in the design of apparatus and equipment.

Additional opportunities to reduce trauma related fatalities in the fire service were identified by the NIOSH report for Leading Recommendations for Preventing Firefighter Fatalities, 1998 - 2005. Improvement in fire departments standard operating procedures (SOPs) and guidelines is the largest area of potential impact. This includes ensuring that SOPs are developed and followed and that firefighters receive refresher training, develop and enforce SOPs for the safe operation of emergency vehicles, enforce the use of seatbelts, develop and implement an incident command system (ICS) and have written maintenance procedures for self contained breathing apparatus (SCBA). Other factors such as establishing good communication systems for events and following incident command protocols to ensure that one person is responsible for the overall coordination and direction of the activities is critical.

SOP development for safe driving of motor vehicles is another area that can prevent injuries and fatalities. This includes driver training, maintenance programs, use of seatbelts by all occupants and proper placement of equipment so that it does not interfere with a driver's ability to operate controls. The use of appropriate personal protective equipment (PPE) is critical for preventing fatalities and injuries. This includes the proper use and inspection of turnout gear, SCBAs, high visibility clothing and use of proper water rescue helmet and personal floatation device when operating at a water incident. Additional aspects of ensuring fire department strategies and tactics incorporate safety elements and the implementation of dedicated rapid intervention teams (RIT) can all have a positive effect on reducing the number of trauma related fatalities. Lastly, the level of staffing at an event is critical in preventing firefighter injuries and fatalities. By ensuring that at least four fire fighters are on the scene before initiating interior firefighting operations, this allows for two-in and two-out, the second team being a backup to the first in case emergency actions are required. (DHHS)

Additional studies on the effectiveness of firefighter wellness programs have shown that fitness programs are effective at preventing firefighter mortality. Wagner, et al (2006) studied career firefighters in Hamburg, Germany and their research concluded that a "strong healthy worker effect was observed" with the career firefighters that engaged in physical fitness. Their research determined that even though firefighters were exposed to a variety of hazards on their jobs, maintaining their health status prevented them from many diseases. However, a second study by Demers, et al (1992) from the United States showed that mortality for firefighters due to all causes "was less than expected based upon United States rates for white men." However, these firefighters were at higher risk for some types of cancer including brain and lymphatic cancers with the risk of "lymphatic and hematopoietic cancers" being the great for "men with at least 30 years of exposed employment. Additional research on the potential positive synergistic effects of wellness benefits and firefighter occupational exposure is certainly warranted.

Summary
In order to have a positive impact on reducing the number of injuries and fatalities in the fire service, a concerted effort is needed in order to change the knowledge of firefighters on the acceptable level of risks that they take in performing their duties. Fire departments can have a positive effect on this by implementing the variety of recommendations discussed above with particular focus on promoting cardiovascular health, wellness and fitness to prevent cardiovascular related diseases, the use of PPE and seatbelts by firefighters and motor vehicle safety focusing on defensive driving. Focus on these areas and continued education of fire service personnel in these aspects will hopefully have a positive effect on reducing firefighter injury, illness and fatalities and on improving the culture.

References
1) BLS. Occupational Outlook Handbook, 2010 - 2011 Edition. Downloaded on March 6, 2011 from http://www.bls.gov/oco/ocos329.htm

2) Demers P, Heyer N, Rosenstock L (1992). Mortality among firefighters from three northwestern United States cities. British Journal of Industrial Medicine 1992; 49: 664-670.

3) Fahy R (2005). U.S. firefighter fatalities due to sudden cardiac death, 1995-2004. Quincy, MA: National Fire Protection Association.

4) IAFC (International Association of Fire Chiefs). Americas Fire Service. Downloaded on March 6, 2011 from http://www.iafc.org/associations/4685/files/fireservice.pdf

5) Kales S, Soteriades E, Christoudias S, and Christiani D (2003). "Firefighters and on-duty deaths from coronary heart disease: a case control study" Environ Health. 2003; 2: 14.

6) LMCIT (League of Minnesota Cities). Trends in Firefighter Injuries. March 2010.

7) NIOSH (2007). Preventing Fire Fighter Fatalities Due to Heart Attacks and Other Sudden Cardiovascular Events. Publication No. 2007-133.

8) NIOSH (2008). Publication Number 2009-100 November 2008. NIOSH Fire Fighter Fatality Investigation and Prevention Program - Leading Recommendations for Preventing Fire Fighter Fatalities, 1998 - 200. Downloaded on March 6, 2011 from http://www.cdc.gov/niosh/fire/

9) NIST (National Institute of Standards and Technology) (2004). The Economic Consequences of Firefighter Injuries and Their Prevention. August 2004. Downloaded on April 3, 2011 from http://www.fire.nist.gov/bfrlpubs/NIST_GCR_05_874.pdf

10) NFFF (National Fallen Firefighter Foundation). "Everyone Goes Home Firefighter Life Safety Initiative". Downloaded on March 6, 2011 from www.everyonegoeshome.com

11) U.S. Fire Administration. Topical Fire Report Series Fire-Related Firefighter Injuries Reported to NFIRS. Volume 11, Issue 7, February 2011. Downloaded on March 6, 2001 from http://www.usfa.dhs.gov/downloads/pdf/statistics/v11i7.pdf

12) Wagner N, Berger J, Flesch-Janys D, Koch P, Köchel A, Peschke M, and Ossenbach T (2006). "Mortality and life expectancy of professional fire fighters in Hamburg, Germany: a cohort study 1950 - 2000". Environ Health. 2006; 5: 27. Published online 2006 October 4.

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