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Executive Summary

On November 7, 2016, at 2352 hours a 58-year-old male volunteer Fire Chief (FC) responded to a 

tractor trailer truck fire and served as Incident Commander. After the fire was knocked down, the FC 

suddenly collapsed as he was talking with the driver of the truck. An ambulance was dispatched at 

0002 hours. Fire Service personnel on scene initiated cardiopulmonary resuscitation and a police 

officer retrieved an AED (automated external defibrillator) from his patrol car and provided several 

shocks. The ambulance arrived on scene at 0018 hours and initiated advanced cardiac life support, 

which was continued en route to the hospital emergency department (ED). Hospital ED personnel 

continued resuscitation efforts unsuccessfully for approximately 20 minutes. The FC was pronounced

dead on November 8 at 0117 hours.

The medical examiner’s report listed the immediate cause of death as acute myocardial infarction

(heart attack). The autopsy report documented an acute thrombosis in the left anterior descending 

coronary artery. NIOSH investigators concluded that the physical/emotional stress of the emergency 

response may have triggered the cardiovascular event.

The FC had several risk factors for coronary artery disease and heart attack. In addition to male sex,

age over 45 years, and family history, he was a smoker [AHA 2016; NHLBI 2016].

Key Recommendations

• Ensure that all fire fighters receive an annual medical evaluation consistent with National Fire 

Protection Association (NFPA) 1582, Standard on Comprehensive Occupational Medical 

Program for Fire Departments.

• Ensure fire fighters are cleared for duty by a physician knowledgeable about the physical 

demands of fire fighting, the personal protective equipment used by fire fighters, and the 

various components of NFPA 1582.

• Phase in a mandatory comprehensive wellness and fitness program for fire fighters.

• Perform an annual physical performance (physical ability) evaluation.
For further information, visit the program website at www.cdc.gov/niosh/fire or call toll free 1-800-CDC-INFO (1-800-232-4636).

Page ii

The National Institute for Occupational Safety and Health (NIOSH), an institute within the Centers for Disease Control and 

Prevention (CDC), is the federal agency responsible for conducting research and making recommendations for the prevention of 

work-related injury and illness. In 1998, Congress appropriated funds to NIOSH to conduct a fire fighter initiative that resulted in the 

NIOSH Fire Fighter Fatality Investigation and Prevention Program, which examines line-of-duty deaths or on-duty deaths of fire 

fighters to assist fire departments, fire fighters, the fire service and others to prevent similar fire fighter deaths in the future. The 

agency does not enforce compliance with state or federal occupational safety and health standards and does not determine fault or 

assign blame. Participation of fire departments and individuals in NIOSH investigations is voluntary. Under its program, NIOSH 

investigators interview persons with knowledge of the incident who agree to be interviewed and review available records to develop 

a description of the conditions and circumstances leading to the death(s). Interviewees are not asked to sign sworn statements and 

interviews are not recorded. The agency's reports do not name the victim, the fire department, or those interviewed. The NIOSH 

report's summary of the conditions and circumstances surrounding the fatality is intended to provide context to the agency's 

recommendations and is not intended to be definitive for purposes of determining any claim or benefit.

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Introduction

On November 7, 2016, at 2352 hours a 58-year-old male volunteer Fire Chief (the “FC”) responded to 

a tractor trailer truck fire and served as Incident Commander. The FC collapsed on scene 16 minutes 

later after suffering a major heart attack. The U.S. Fire Administration notified NIOSH of this fatality 

on November 8, 2016. NIOSH contacted the affected fire department (FD) on November 10, 2016, and 

again on June 7, 2017, to gather additional information and to initiate the investigation. On June 16, 

2017, a contractor for the NIOSH Fire Fighter Fatality Prevention and Investigation Program (the 

NIOSH investigator) conducted an on-site investigation of the incident.

During the investigation, the NIOSH investigator interviewed the following people:

 Fire Chief

Assistant Fire Chief

 Fire fighter who drove the Rescue Truck 

Daughter of the FC

The NIOSH investigator reviewed the following documents:

 FD incident report

Emergency medical service (ambulance) report

Hospital emergency department (ED) records

Death certificate

Autopsy report

Investigation

On November 7, 2016, at 2352 hours a 58-year-old male volunteer FC was notified of a tractor trailer 

truck fire on the exit ramp of a major interstate. The FC responded to his fire station, made 

assignments for responding personnel and apparatus, and rode to the scene in the passenger seat of the 

Rescue Truck. The FC left the Fire Station at 2356 hours. After they traveled a few blocks, the Driver 

asked the FC if he was going to radio dispatch that they were en route because the FC typically did this 

just as they were leaving the station. The FC responded affirmatively and then made the radio 

transmission. The Driver asked the FC if everything was okay and he responded that he was fine, just 

not feeling well. At the time, the Driver thought it was probably because they had just been awakened 
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for the call. The FC arrived on scene at 0002 hours (the next day) and assumed incident command; he 

directed fire suppression activities and helped identify hot spots once the main fire was extinguished. 

After the fire was under control, the FC walked back behind the fire apparatus to where the truck 

driver was standing. The FC began talking to the driver then suddenly collapsed. The driver of the 

truck called for help and department members ran approximately 100 feet to find the FC supine on the 

ground. Emergency Medical Services trained fire fighters assessed the FC, found him to be 

unconscious and pulseless, and began chest compressions. An AED was retrieved from the police 

officer’s vehicle and was attached to the FC. Based on the instructions provided by the AED, multiple

shocks were delivered prior to the arrival of the ambulance. Emergency Medical Services personnel 

provided ventilation via a bag-valve mask. An ambulance arrived on scene at 0037 hours. The FC was 

unresponsive, pulseless, and exhibiting agonal breathing. The FC’s bunker pants were removed and he 

was placed on a long board. The AED advised that a shock be given and another shock was delivered. 

The FC was loaded into the ambulance which departed the scene at 0042 hours.

En route to the hospital, the initial rhythm check showed ventricular fibrillation and manual 

defibrillation was performed. Paramedics gained intraosseous access and provided multiple rounds of 

cardiac medications. Paramedics tried to intubate the FC but were unsuccessful. The FC was 

defibrillated four times during transport. The ambulance arrived at the ED at 0058 hours.

The initial cardiac rhythm at the ED was asystole. The rhythm changed to pulseless electrical activity 

at 0108 hours and remained so until the FC’s death. The FC was intubated at the hospital and received 

additional rounds of cardiac medications. At 0115 hours, a cardiac ultrasound was performed and no 

meaningful cardiac movement was noted. At 0117 hours, resuscitation efforts were discontinued and 

the FC was pronounced dead.

Medical Findings

The Medical Examiner’s report identified the cause of death as acute myocardial infarction. A 

thrombus was found in the left anterior descending coronary artery. There was also severe coronary 

arteriosclerosis and moderate aortic arteriosclerosis. The FC also had cardiac enlargement (540 grams), 

severe left ventricular hypertrophy (LVH, 2.4 centimeters), and myocardial fibrosis. See Appendix A 

for a more detailed description of autopsy findings.

The FC regularly engaged in physical work (such as flooring and carpentry). He had not seen a 

physician in many years and was taking no medications other than aspirin. He had a family history of 

coronary artery disease and was a smoker. According to family, he was 70 inches tall and based on 

hospital ED records he was 176 pounds, giving him a BMI (body mass index) of 25.3 kilograms per 

meter squared (kg/m2) [NHLBI no date]. 

Fire Department
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At the time of the NIOSH investigation, the FD consisted of approximately 20 uniformed personnel

operating out of a single fire station. It served a population of approximately 3,500 in a geographic 

area of 225 square miles. In 2016, the FD responded to approximately 100 calls.

Employment and Training

Applicants must be at least 21 years of age, possess a valid state driver’s license, have a high school 

diploma or equivalent, and complete an application. The Fire Chief reviews applications and the 

membership votes on new members. The new member is on probation for 1 year. The FC had been 

with the FD for 27 years and had been Chief of the Department for 3 years.

Medical Evaluation/Wellness and Fitness Programs

The FD does not require preplacement medical evaluations for applicants or for members. Members 

are not required to provide medical clearance following a serious injury or illness. When members join 

the FD, they are required to provide a note from their physician stating that they are cleared to wear 

self-contained breathing apparatus (SCBA). The FD does not offer a comprehensive wellness/fitness 

program as recommended by the IAFF/IAFC Wellness Fitness Initiative [IAFF, IAFC 2008]. 

Discussion

Sudden Cardiac Events

In the United States, atherosclerotic coronary heart disease (coronary artery disease) is the most 

common risk factor for cardiac arrest and sudden cardiac death [Meyerburg and Castellanos 2008]. 

Risk for its development is grouped into non-modifiable and modifiable risk factors. Non-modifiable 

risk factors include age older than 45, male gender, and family history of coronary artery disease. 

Modifiable risk factors include diabetes mellitus, smoking, high blood pressure (hypertension), 

unhealthy blood cholesterol levels, and obesity/physical inactivity [AHA 2016; NHLBI 2016]. The FC

was male, over 45, had a family history of cardiovascular disease, and was a smoker.

Coronary Artery Disease

Coronary artery disease refers to atherosclerotic plaque in the coronary arteries and the complications 

of the plaque. The narrowing of the coronary arteries by atherosclerotic plaques occurs over many 

years, typically decades [Libby 2013]. However, the growth of these plaques probably occurs in a 

nonlinear, often abrupt fashion. Plaque buildup that restricts blood flow and prevents sufficient oxygen 

delivery to the myocardium is called ischemia, and can cause chest pain (angina), particularly with 

exertion. Heart attacks or myocardial infarctions typically occur with the sudden development of 

complete blockage (occlusion) in one or more coronary arteries that have not developed a collateral 

blood supply. This sudden blockage is primarily due to blood clots (thromboses) forming on top of a 

ruptured atherosclerotic plaque [Libby 2013]. Heart attacks and sudden cardiac death can be triggered 

by heavy physical exertion [Albert et al. 2000; Mittleman et al. 1993; Willich et al. 1993], including 

snow shoveling [Franklin et al. 2001] and fire fighting activity, including an alarm response [Kales et 
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al. 2003; Kales et al. 2007; NIOSH 2007]. 

Establishing the occurrence of an acute heart attack requires any of the following: characteristic 

electrocardiogram changes, elevated cardiac enzymes, or coronary artery thrombus/plaque rupture. In 

this case, the FF had a coronary thrombus in a main coronary artery (left anterior descending coronary 

artery) at autopsy confirming a heart attack.

Left Ventricular Hypertrophy/Cardiomegaly 

LVH (thickening of the heart’s left ventricle) is a common finding among individuals with longstanding high blood pressure, a heart valve problem, obesity, or cardiac ischemia [Cramariuc and 

Gerdts 2016; Cuspidi et al. 2014; Korre et al. 2016; Siegel 1997; Tavora et al. 2012]. LVH and 

cardiomegaly (an enlarged heart) are both structural heart changes that increase the risk for 

arrhythmias and sudden cardiac death [Chatterjee et al. 2014; Kahan and Bergfeldt 2007; Spirito et al. 

2009; Tavora et al. 2012]. The FC had cardiomegaly and severe LVH. 

Occupational Medical Standards for Structural Fire Fighters

Nearly half of all fire fighter duty-related deaths are caused by sudden cardiac death. Firefighting 

results in multiple cardiovascular changes that could lead to plaque rupture or arrhythmogenic changes 

in individuals with underlying cardiovascular disease [Smith et al. 2016]. Research on fatalities have 

found that autopsies have shown atherosclerosis in a majority of fatality cases [Geibe et al. 2008; Kales 

et al. 2003]. To reduce the risk of sudden cardiac events or other incapacitating conditions among fire 

fighters, the NFPA developed 1582, Standard on Comprehensive Occupational Medical Program for 

Fire Departments [NFPA 2013a]. Regarding screening asymptomatic fire fighters for coronary artery

disease, NFPA 1582 recommends basing this decision on presence of risk factors for the disease. For 

fire fighters (such as the FC) with two non-modifiable risk factors (male sex and age >45 years), the 

presence of just one additional risk factor (e.g., hypertension, high cholesterol, diabetes, or smoking) is 

enough to recommend screening with a symptom-limiting exercise stress test [NFPA 2013a]. 

The FD did not require medical evaluations for candidates or members, and the FC rarely saw a 

physician. Although his blood pressure, cholesterol level, and diabetes status were not known, the FC 

was a smoker. With the presence of this risk factor in a male over age 45, an exercise stress test would 

have been recommended according to NFPA 1582 guidance [NFPA 2013a].

Recommendations

Recommendation #1: Ensure that all fire fighters receive an annual medical evaluation consistent 

with NFPA 1582, Standard on Comprehensive Occupational Medical Program for Fire 

Departments.

Discussion: Guidance regarding the content and frequency of these medical evaluations can be found 

in NFPA 1582 [NFPA 2013a]. These evaluations are performed to determine a fire fighter’s medical 
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ability to perform duties without presenting a significant risk to the safety and health of themselves or 

others. This medical evaluation should be consistent with the requirements of NFPA 1582.

Recommendation #2: Ensure fire fighters are cleared for duty by a physician knowledgeable about 

the physical demands of fire fighting, the personal protective equipment used by fire fighters, and 

the various components of NFPA 1582.

Discussion: According to NFPA 1582, the FD should require that physicians are familiar with the 

physical demands of fire fighting and the risks that fire fighters encounter and should guide, direct, and 

advise members with regard to their health, fitness, and suitability for duty [NFPA 2013a]. The 

physician should review job descriptions and essential job tasks required for all FD positions to 

understand the physiological and psychological demands of fire fighting and the environmental 

conditions under which fire fighters perform, as well as the personal protective equipment they must 

wear during various types of emergency operations. 

Recommendation #3: Phase in a mandatory comprehensive wellness and fitness program for fire 

fighters.

Discussion: Guidance for fire department wellness/fitness programs to reduce risk factors for 

cardiovascular disease and improve cardiovascular capacity is found in NFPA 1583, Standard on 

Health-Related Fitness Programs for Fire Fighters, the IAFF/IAFC Fire Service Joint Labor 

Management Wellness/Fitness Initiative, the U.S. Fire Administration Health and Wellness Guide for 

the Volunteer Fire and Emergency Services, and in Firefighter Fitness: A Health and Wellness Guide

[IAFF, IAFC 2008; NFPA 2015; Schneider 2010; USFA 2009]. Worksite health promotion programs 

have been shown to be cost effective by increasing productivity, reducing absenteeism, and reducing 

the number of work-related injuries and lost work days [Aldana 2001; Stein et al. 2000]. Health 

promotion programs for fire fighters have been shown to reduce coronary heart disease risk factors and 

improve fitness levels, with mandatory programs showing the most benefit [Blevins et al. 2006; 

Dempsey et al. 2002; Womack et al. 2005].

The FD has does not have exercise equipment available to members and does not have a 

wellness/fitness program. Given the FD’s structure and budget limitations, helpful resources for 

starting a program may include the Heart-Healthy Firefighter Program developed by the National 

Volunteer Fire Council [NVFC, no date] and the Health and Wellness Guide for the Volunteer Fire 

and Emergency Services [USFA 2009].

Recommendation #4: Perform an annual physical performance (physical ability) evaluation.

Discussion: NFPA 1500 recommends fire department members who engage in emergency operations 

be annually evaluated and certified by the FD as having met the physical performance requirements 

identified in paragraph 10.2.3 of the standard [NFPA 2013b]. This is recommended to ensure fire 

fighters are physically capable of performing the essential job tasks of structural fire fighting. The 

physical ability test could be incorporated into the FD’s training program.
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References

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http://www.heart.org/HEARTORG/Conditions/HeartAttack/UnderstandYourRiskofHeartAttack/Under

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Cramariuc D, Gerdts E [2016]. Epidemiology of left ventricular hypertrophy in hypertension: 

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Dempsey WL, Stevens SR, Snell CR [2002]. Changes in physical performance and medical measures 

following a mandatory firefighter wellness program. Med Sci Sports Exerc 34(5):S258.

Franklin BA, George P, Henry R, Gordon S, Timmis GC, O’Neill WW [2001]. Acute myocardial 

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11377355.

Geibe JR, Holder J, Peeples L, Kinney AM, Burress JW, Kales SN [2008]. Predictors of on-duty 

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Investigator Information

This incident was investigated by the NIOSH Fire Fighter Fatality Investigation and Prevention 

Program, Cardiac and Medical Line-of-Duty Deaths (LODD) Investigations Team, located in 

Cincinnati, Ohio. Denise L. Smith, Ph.D., led the investigation and authored the report. Dr. Smith is

Professor of Health and Exercise Sciences, and Director of the First Responder Health and Safety 

Laboratory at Skidmore College, where she was recently awarded the Tisch Family Distinguished 

Professorship. She is also a member of the NFPA Technical Committee on Occupational Safety and 

Health. Dr. Smith was working as a contractor with the NIOSH Fire Fighter Fatality Investigation and 

Prevention Program, Cardiac and Medical LODD Investigations Team, during this investigation. 

Wendi Dick, MD, MSPH, provided medical consultation and contributed to the report. Dr. Dick is 

Lead for the Cardiac and Medical LODD Investigations Team in Cincinnati.
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Disclaimer

Mention of any company or product does not constitute endorsement by the National Institute for 

Occupational Safety and Health (NIOSH). In addition, citations to websites external to NIOSH do not

constitute NIOSH endorsement of the sponsoring organizations or their programs or products. 

Furthermore, NIOSH is not responsible for the content of these websites.
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Appendix A

Autopsy Findings

 Coronary artery disease

o Generalized severe calcified arteriosclerotic plaque

o Left circumflex is 25% narrowed by plaque

o Left main artery is 76%-100% narrowed by calcified plaque 

o Left anterior descending artery is 76%-100% narrowed by calcified plaque

o Right coronary artery is 25% narrowed by plaque

o Thrombus in left anterior descending artery

o Lateral left ventricular softening and mottling of the myocardium due to recent myocardial 

infarction/necrosis

 Structural heart disease

o Cardiomegaly (heart weighed 540 grams; predicted normal weight is 375 grams [ranges 

between 284 and 495 grams as a function of sex and body weight) [Silver and Silver 2001]

o Severe left ventricular hypertrophy (left ventricular thickness – 2.4 centimeters [cm]; normal at 

autopsy is 0.76 to 0.88 cm) [Colucci and Braunwald 1997]

 Microscopic 

o Left ventricular myocardial fibrosis

 Normal cardiac valves

 No evidence of a pulmonary embolus (blood clot in the lung arteries)

 Blood analysis negative for drugs of abuse

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