Early diagnosis of firefighter mental and physical health issues

It can extend or improve the quality of life.

The leading cause of fatalities on wildland fires is medical issues, according to data for 1990 through 2014 supplied by the National Interagency Fire Center. The numbers would probably be significantly higher if deaths that occurred away from the fireline but caused by the job were figured in, such as leukemia, testicular cancer, lung cancer, brain cancer, bladder cancer, ureter cancer, colorectal cancer, and non-Hodgkins’s lymphoma. Many jurisdictions list these as “presumptive cancers” and will automatically cover the medical bills of firefighters diagnosed with the conditions.

Another medical issue affecting firefighters, the elephant in the room, is mental health, something that is rarely talked about in a job where physical prowess and endurance is often used as a measuring stick. We are reminded of a firefighter who earlier in his career was highly regarded and respected, but has changed to the point where he is causing serious problems on and off the job. Some of his colleagues think he might benefit from professional psychiatric help.

Early diagnosis and treatment of physical and mental conditions can extend or improve the quality of life. We often hear, “If you see something, say something”. Usually that is used in the context of possibly dangerous conditions or crew resource management, but it can also apply to our co-workers who might need treatment for a dangerous physical or mental issue.

All firefighters and their families need to see the excellent nine-minute video covering the physical and mental health of firefighters  produced by Edmonton Fire Rescue. It was made possible by the family of deceased firefighter Edward James Paul (1954-2015).

Watch the video.

And, be careful out there.

Prevention of heat related injuries among wildland firefighters

When we were writing the July 13 article about Frank Anaya, the latest California inmate firefighter that died on a fire, we discovered details about a previous inmate fatality that were shocking. It involved the death of Jimmy Randolph in August of 2012 whose passing was associated with heat stroke. The shocking part was that Mr. Randolph was found unresponsive one morning in the sleeping area on a fire and died in a hospital seven hours later. He had complained of a headache the previous evening and was checked out by the medical unit, but apparently no one was aware of the seriousness of his condition.

Here is an excerpt from a summary of the fatality from wlfalswaysremember.org:

Firefighter Jimmy Randolph was assigned to the Buck Fire as a part of a strike team. At approximately 1800 hours on August 18, 2012, Firefighter Randolph advised a correctional officer that he had a headache. He was escorted to a medical team, evaluated, and given a three-day no-work note. At approximately 0530 hours the next morning, Fire fighter Randolph could not be awakened. He was treated and transported to the Desert Regional Hospital in Palm Springs. With his family by his side., he was pronounced dead at 1230 hours on August 19, 2012. The cause of death was listed as anoxic encephalopathy combined with complications of heat stroke.

Anoxic encephalopathy is a condition where brain tissue is deprived of oxygen and there is global loss of brain function. The longer brain cells lack oxygen, the more damage occurs.

I checked the weather for August 18, 2012 for San Jacinto, California which is in the general vicinity of the Buck Fire, and the high temperature that day was 92 degrees — a temperature commonly found on a large wildfire in the summer.

Today the National Multi-Agency Coordination Group: issued a memo titled, “Wildland Firefighter Heat Related Injury Prevention, Awareness, and Rhabdomyolysis”.

Here’s how it begins:

The wildland firefighter community has experienced an alarming increase in heat related and other physiological injuries in the last few days. Heat related injuries and Rhabdomyolysis are not the same, but can occur at the same time. Extreme weather conditions are predicted to continue across western states for the next week. The National Weather Service is issuing Heat Warnings for the SWCC, GBCC, RMCC, OSCC, and ONCC.

It is a very well-written document about how to prevent, mitigate, and recognize heat related injuries.

Read it, dammit.

You don’t want to wake up dead.

Full Stop.

The brain needs sleep to perform nightly maintenance — for firefighters and everyone else

At the top of the article: USFS photo.

The brain uses a quarter of the body’s entire energy supply, yet only accounts for about two percent of the body’s mass. So how does this unique organ receive and, perhaps more importantly, rid itself of waste? New research suggests it has to do with sleep.

In the TedMed video above, neuroscientist Jeff Iliff explains the connection between sleep and brain function.

A study of almost 7,000 firefighters from municipal fire departments found that 37 percent screened positive for common sleep disorders, including obstructive sleep apnea, insomnia, restless leg syndrome, and shift work disorder.

The researchers found that compared with sound sleepers, those with a sleep disorder were about twice as likely to have a motor vehicle crash, to nod off while driving, and to have cardiovascular disease or diabetes. They were more than three times as likely to suffer from depression and anxiety.

Wildland firefighters usually work 8-hour shifts —  except when they don’t. While on fires their shift schedules and sleep routines are often disrupted. The 8-hour shift can be extended to 12 to 16 hours, and their usual sleeping and waking times may be changed and sometimes shortened; not unlike the jet lag of traveling to a different time zone. The first shift on a fire may be longer than 16 hours and a crew used to working during the day can be placed on a night shift.

A firefighter sleep study conducted by the Missoula Technology Development Center between 2006 and 2008 found that sleep deprivation contributed to fatigue, stress, and impaired performance of Incident Management Team members.

I talked with pilots and other personnel that traveled with an air tanker to a new assignment. Depending on their original location, they flew across two to four time zones and after arrival, they started work about two hours earlier than usual. So the net change was four to six hours worth of jet lag when taking the new work schedule into account. After a couple of days at the new site two crewmembers told me that they were really tired, even though they were not physically working much harder than normal. Their supervisor eventually recognized this and made sure they got a day off.

That kind of disruption in a work/sleep/wake schedule is common among wildland firefighters, especially those that travel long distances to an assignment. It is possible that wildland fire managers do not recognize this and the negative effect it can have, or if they do, may feel there is little they can do to mitigate the problem.

Crew supervisors and incident management teams should at least strive to give firefighters an opportunity to get an adequate amount of quality sleep.

We have written before about the importance of sleep for wildland firefighters. Articles on Wildfire Today tagged “sleep”.

78% of firefighters tested at spike camp on Frye fire had strep throat

Medical Unit
An example of a Medical Unit at a wildfire. In 2012 community members toured the Incident Command Post, including the Medical Unit seen here, at the Springs Fire in Idaho. Inciweb photo.

On June 17 the Incident Management Team (IMT) running the Frye Fire near Safford, Arizona wrote on Inciweb that “21 additional personnel with unknown illness were demobilized.” On June 18 the Tucson News reported that 45 people at the fire had been treated for strep throat, also known as streptococcal pharyngitis.

On June 22 the IMT posted much more information about the “incident within an incident”. A doctor went to the remote Columbine Spike Camp on Mt. Graham where firefighters were staying so they did not have to endure the long round trip each day to the Incident Base. He swabbed the throats of 80 firefighters, with 63 (or 78 percent) testing positive for Streptococcus.

(As of June 24 the Frye Fire has burned over 29,000 acres at Mt. Graham near Safford, Arizona east of Tucson.)

Before and after those shocking test results, the IMT took many actions in order to mitigate the situation.

  • The IMT created an Incident Health Group led by a Medical Unit Leader with the sole function of dealing with the Strep outbreak. (Functional Groups can be quickly created within the Incident Command System to handle specific tasks.  An example of one that is often used is a Structure Protection Group. They may or may not be tied to a specific geographic location.)
  • The Team disinfected pretty much everything in sight.
  • They stopped using the hand-wash station.
  • The caterer was ordered to stop meal production and to dispose of all currently prepared meals. Personnel then were given bottled water and MREs.
  • Symptomatic personnel were isolated, and incoming resources were kept separate from existing personnel.
  • Contracts were issued for a doctor, an RN, and two paramedics to administer testing and provide medication.
  • Treatment with an oral antibiotic for those affected began.
  • The IMT recommended follow-up for the personnel that demobed prior to June 16.
  • When additional personnel presented with symptoms, they were kept isolated from the Incident Command Post population in an isolation/decontamination room where they could get a shower and a change of clothes. They also had access to another isolated room nearby where they could rest and recuperate so as not to expose others while under treatment during contagion.
  • Although the doctor suggested most patients would not be contagious 24 hours after the antibiotic treatment, the IMT decided to extend the period to 48 hours.
  • Graham County Public Health developed an epidemiological investigative process to include interviews and questionnaires with all available parties.

Strep throat affects about 3 million people in the U.S. each year.  With treatment by a medical professional, which often requires lab tests or imaging, it is usually resolved within days or weeks. Common symptoms include sore throat, fever, and swollen lymph nodes in the neck. Rarely, complications can involve the heart or kidneys. Treatment is important to reduce complications.

Thanks and a tip of the hat go out to Tom.
Typos or errors, report them HERE.

Safely training the tactical athlete

Above: Firefighters on the Apple Fire, March 28, 2012. Photo by Bill Gabbert.

Today we are reprising a second article from our archives about heat related injuries and extreme physical exertion among wildland firefighters.

As we reported in the first Throwback Thursday article, Dr. Brent Ruby, who has studied firefighters as they worked on fires, said regarding the 2011 hyperthermia fatality on the CR 337 fire in Texas:

The lessons learned from this research clearly indicate that the best protection against a heat injury is reducing work rate.

Aggressive hydration strategies are over-preached and may provide a false sense of protection. It should be emphasized that the autopsy report as described in the fatality report indicated no signs of dehydration or electrolyte imbalance.

With that in mind, below is the article we wrote in 2016 after reports were released on two very serious injuries that occurred during the first two days of training for new firefighters.

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Safely training the tactical athlete

EMTAfter reading the Facilitated Learning Analysis (FLA) about the Rhabdomyolysis (Rhabdo) injury that occurred May 2, 2016 in South Dakota on the first day of the fire season after running for more than nine miles before doing uphill sprints, I started thinking about, not so much WHAT happened, but how to prevent similar serious injuries.

A couple of weeks before the Rhabdo case, on April 19 a wildland firefighter in the Northwest suffered a heat stroke while running on day 2 of their season. The employee was unconscious for several hours and spent four days in the hospital.

Both of these exercise-induced conditions can be life-threatening; 33 percent percent of patients diagnosed with Rhabdo develop a quick onset of kidney failure, and 8% of all cases are fatal.

Heat stroke can also kill, according to Medscape:

When therapy is delayed, the mortality rate may be as high as 80%; however, with early diagnosis and immediate cooling, the mortality rate can be reduced to 10%.

These two very serious incidents in a two week period that occurred at the beginning of the fire season should be a wakeup call for agencies employing wildland firefighters.

I am not a medical or exercise specialist, but neither were any of the four members of the South Dakota Rhabdo FLA team. It was comprised of a District Fire Management Officer, a Natural Resources Specialist, an Assistant Superintendent on a Hotshot crew, and an Assistant Fire Engine Operator.

A person might expect that for an exercise-induced injury that is fatal in eight percent of the cases, a medical expert and an exercise physiologist would be members of the team. The FLA concentrated on recognizing symptoms of Rhabdo, which is good. Firefighters need to be be informed, again, about what to look for. But the necessity of treating the symptoms could be avoided if the condition was prevented in the first place.

Prevention was not addressed in the document, except to mention availability of water. Dehydration isn’t the leading cause of Rhabdo, which is caused by exertion, but it can be a contributing factor.

With two life-threatening medical conditions on firefighting crews in a two-week period that occurred during mandatory exercise on day one and two of training, medical and exercise professionals perhaps could have evaluated what caused the injuries, and suggested how to design and implement a physical fitness program that would lessen the chances of killing firefighters on their first or second day on the job. But the LEARNING opportunity of the FLA was squandered.

The wildland fire agencies are not alone in hiring people off the streets and throwing them into a very physically demanding job. The military does this every day, as do high school athletic programs. There is probably a large body of research that has determined how to turn a person into an athlete without putting their lives in danger.

While the three firefighters and the natural resources specialist I’m sure meant well and did the best they could to write the FLA within the limits of their training and experience, the firefighting agencies need to get serious about a professional level exercise training program. After all, they are employing TACTICAL ATHLETES.

This issue is serious enough that the NWCG (since there is no National Wildland Firefighting Agency) should hire an exercise physiologist who can design, implement, and monitor a program for turning people off the street into tactical firefighting athletes.