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Executive Summary

On April 27, 2016, a 58-year-old male paid-on-call fire fighter (FF) responded to a brush fire call. He 

drove the tanker to the scene and assisted with suppression operations. After approximately 10 minutes 

on the scene, he collapsed. Fire fighters on the scene evaluated the FF, found that he was breathing, 

and initiated care. While he was being treated the FF stopped breathing and became pulseless.

Cardiopulmonary resuscitation (CPR) was initiated, and shocks were delivered with an automated 

external defibrillator (AED). An ambulance arrived on scene and the crew took over CPR and initiated

advanced life support. During care rendered by the paramedics and fire fighters, the FF regained a 

spontaneous pulse, but he remained unresponsive while being transferred to the area medical center. At 

the medical center blood testing revealed elevated troponin levels consistent with a myocardial 

infarction (heart attack). The FF was stabilized and transported to a larger medical center, where he 

received a stent to the left main coronary artery. However, magnetic resonance imaging on May 2,

2016, revealed anoxic brain damage due to lack of oxygen. On May 5, 2016, the breathing tube was 

removed and the FF died. 

The death certificate listed the cause of death as myocardial infarction due to atherosclerotic 

cardiovascular disease. No autopsy was performed. NIOSH concludes that the emergency response and 

light to medium physical exertion of supporting operations at a fire scene may have triggered the FF’s

heart attack. 

Key Recommendations

• Ensure that all fire fighters receive a preplacement and annual medical evaluation consistent 

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

Departments, to identify fire fighters at increased risk for heart disease or other conditions.

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

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

and the various components of NFPA 1582.

• Perform candidate and annual physical ability evaluations for all fire fighters involved in 

emergency operations.

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

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 April 27, 2016, a 58-year-old paid-on-call, male FF suffered a heart attack and collapsed while 

supporting operations at a brush fire. He regained spontaneous circulation during emergency medical 

services treatment and was transported to a medical center where he was stabilized and then 

transported to a larger medical center where he received a stent to the left main coronary artery. 

However, the FF sustained severe brain injury and he died 8 days after his collapse. The U.S. Fire 

Administration notified NIOSH of this fatality on May 6, 2016. NIOSH contacted the affected fire 

department (FD) on May 6, 2016, and again on February 2, 2017, to gather additional information and

to initiate the investigation. On February 9, 2017, a contractor for the NIOSH Fire Fighter Fatality 

Prevention and Investigation Program conducted an on-site investigation of the incident.

During the investigation, NIOSH personnel interviewed the following people:

 Fire Chief

 FFs who were working with the FF at the scene

 FF’s daughter

NIOSH personnel reviewed the following documents:

 FD standard operating guidelines

 FD incident report

 FD injury/illness investigation report

Emergency medical service (ambulance) report

Hospital emergency department (ED) records

 Primary care physician records

Death certificate

Investigation

On April 27, 2016, a 58-year-old male paid-on-call FF responded to a brush fire at 1254 hours. The FF 

responded to the call as the driver of the tanker along with his Chief. The call was for an intentionally 

set brush fire that was out of control. The FF and his Chief arrived on scene at 1301 hours and found 

approximately half an acre of grass and one quarter of an acre of brush on fire. The fire ran along a 

fence line and was fueled by brush that had been cut and stacked along the fence line. It was a clear 

spring day (45°–50°F, winds out of northwest at 10 mph [FD incident report]). The FF, who had

expertise in wildland fire, directed other fire fighters on where to deploy hoselines to most effectively 

suppress the fire. 

At 1310 hours the fire was reported as under control but not fully extinguished. The Chief asked the FF 

to retrieve additional hose from the engine. The FF walked approximately 50 feet up a gentle slope and 

retrieved 50 feet of hoseline from the engine (approximately 35–40 pounds). While at the engine he 
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spoke briefly to another fire fighter and was in no apparent distress. He started back down the gently

sloped hill toward the fire. Moments later, the fire fighter who was at the engine heard the Chief call 

over the radio for a “man down.” The fire fighter from the engine ran toward the fire where the Chief 

was working and realized the FF had collapsed. The Chief and other fire fighters on the scene

evaluated the FF and found him to be nonresponsive with difficulty breathing. The FF was provided 

oxygen and assisted ventilation. An ambulance was requested at 1313 hours. While receiving care the 

FF stopped breathing, and CPR was initiated. A fire fighter/first responder who was in his vehicle at 

the scene responded to the FF with an AED and his medical bag. The FF lost his pulse, and the AED 

revealed that a shock was advised. A shock was given, CPR was resumed until the FF was reevaluated,

and another shock was administered.

An ambulance arrived on scene at 1324 hours. Paramedics evaluated the FF and found him to be 

pulseless and breathless with no signs of life. They applied the defibrillator pads, analyzed the rhythm,

and delivered a shock. They gained intravenous and intraosseous access and administered cardiac 

medications. The FF was intubated with an endotracheal tube with location confirmed by visualization, 

condensation in the tube, and end-tidal CO2. Paramedics provided another shock. The FF regained a 

spontaneous pulse and paramedics continued to provide ventilation via endotracheal tube and bag 

valve device during transport to the hospital.

When the FF arrived at the ED at 1412 hours, he remained unresponsive but had a spontaneous pulse 

of 107 beats per minute and a blood pressure of 120/65 millimeters of mercury (mmHg). ED personnel 

collected blood, placed a nasogastric tube and Foley catheter, and administered medications. Blood 

results revealed elevated troponin levels, and the electrocardiogram (ECG) revealed ST segment 

changes consistent with an anterolateral myocardial infarction. At the ED the FF was cooled with ice. 

ED staff decided to send the FF to a university-based medical center for hypothermic protocol and 

possible cardiac intervention. (Cooling the body may prevent damage to the brain after it goes without 

oxygen during cardiac arrest [Arrich et al. 2016].) At 1530 hours, an ambulance arrived to transport the 

FF; the FF’s blood pressure was 120/60 mmHg, his pulse was 82, and he was in normal sinus rhythm 

but he remained unconscious. The FF’s condition was listed as critical. He remained stable throughout 

transport and care was transferred to the medical center at 1610 hours.

An echocardiogram performed upon arrival at the medical center revealed a mildly dilated left 

ventricular cavity, severely reduced systolic function (ejection fraction of 15%–20%; normal is 50%–

70% [AHA 2015]), and severe diffuse hypokinesis (weakened contraction of the heart muscle). The FF 

was taken to the cardiac catheterization lab where a stent was placed in the left main coronary artery. 

Despite establishing good blood flow to the heart, magnetic resonance imaging on May 2, 2016, found 

diffuse anoxic brain injury. On May 5, 2016, the FF was extubated and died at 1400 hours from 

respiratory failure secondary to global anoxic brain damage due to cardiac arrest.

Medical Findings

The death certificate completed by the medical examiner identified the cause of death as myocardial 

infarction due to atherosclerotic cardiovascular disease. Because diagnostic testing had identified the 

cause of death, no autopsy was performed.
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The FF had a history of hypertension, dyslipidemia, diabetes mellitus, peripheral artery disease 

(stenting to right iliac artery), and coronary artery disease. He had a myocardial infarction in July 2009

and was diagnosed with Type II diabetes mellitus at that time.

The FF was a smoker with no known family history of cardiovascular disease based on interview with 

family. Medical records indicated that he was 72 inches tall and weighed 205 pounds, giving him a 

body mass index of 27.8 kilograms per meter squared [CDC 2015]. At his most recent medical 

examination, in October 2015, the FF had a blood pressure of 108/54 mmHg (normal resting is 

between 90/60 and 120/80 mmHg) and testing revealed a hemoglobin A1C level of 6.7% (a level 

below 7% is recommended for diabetics). The last laboratory testing available in his medical records 

was from January 2010; these tests showed that the FF had total cholesterol of 116 mg/dL (desirable < 

200 mg/dL), low density lipoprotein or “bad” cholesterol of 66 mg/dL (optimal < 100 mg/dL), 

triglycerides of 90 mg/dL (normal < 150 mg/dL), and high density lipoprotein or “good” cholesterol of 

32 (normal > 40 mg/dL) [NHLBI 2005]. The FF performed an exercise stress test on February 11, 

2010. The duration of the test was 7 minutes and 29 seconds, during which the FF reached a peak heart 

rate of 133 beats per minute, which was below the target heart rate, and a maximal work rate of 8.5 

metabolic equivalents (METs). On August 4, 2014, the FF performed a stress echocardiogram and 

reached a maximal heart rate of 126 beats per minute, which was less than the target heart rate, and 

based on the duration of the test had a maximal work rate of < 7 METs. The stress echocardiogram 

also showed moderately depressed left ventricle global function (ejection fraction = 40%), severe 

hypokinesis of the apical-anteroseptal and mid-anterior regions of the left ventricle, and akinesis (no

contraction) of the apical region of the left ventricle.

Fire Department

At the time of the NIOSH investigation, the volunteer FD consisted of approximately 25 uniformed 

personnel working out of a single fire station. It served a population of approximately 4,500 in a 

geographic area of 43 square miles. In 2016, the FD responded to over 140 incidents, approximately 

half of which were fire calls and half of which were rescue calls. The FD also provided assistance on 

approximately 10 emergency medical calls.

Employment and Training

To join the FD, an interested person must be at least 18 years of age (or 16 years of age if applying to 

the cadet program), have a valid driver’s license, be a resident of the town, and complete an 

application. Applicants must pass a driving background check and meet with the Chief or other officer 

to review expectations and standard operating guidelines. The Chief discusses the potential candidate 

with the other officers and approves a new member.

New members receive in-house training, must attend monthly departmental training, and are sent to a 

neighboring FD that sponsors a course for state certification as Fire Fighter I. Typically, the training 

course is structured to meet one to two nights per week for approximately 10 months, and courses 

usually start in the fall of the year. The FF had been with the FD for over 40 years and had also served 
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as a career fire fighter in a neighboring community for 32 years before retiring in 2010. The FF also 

served as the Fire Warden.

Medical Evaluations and Wellness/Fitness Programs

The FD does not require medical evaluations for applicants and does not require periodic medical 

evaluations for members. If the FD is aware of a serious injury or illness, it requires a note from the 

member’s primary care physician before the member can return to fire fighting duty. The FD does not 

have fitness equipment in the station and does not offer a wellness/fitness program.

Discussion

Sudden Cardiac Events

In the United States, atherosclerotic coronary heart disease is the most common risk factor for cardiac 

arrest and sudden cardiac death [Meyerburg and Castellanos 2008]. Risk factors for its development 

are grouped into non-modifiable and modifiable 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, high blood cholesterol, and obesity/physical inactivity 

[AHA 2016; NHLBI 2016]. The FF had known coronary artery disease having suffered a previous 

heart attack and having stents. He also had multiple risk factors, including diabetes mellitus, smoking, 

hypertension, dyslipidemia, and obesity (based on medical records). He also had known peripheral 

vascular disease. Recent testing also revealed that he had diminished heart function, impaired work

(aerobic) capacity, as well as a decline in work capacity on the basis of stress tests between 2010 and 

2014.

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. Heart attacks (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 

atherosclerotic plaques [Libby 2013]. Establishing a recent (acute) heart attack requires any of the 

following: characteristic ECG changes, elevated cardiac enzymes, or coronary artery thrombus. In this 

case, the FF had elevated cardiac enzymes (troponin) and ECG changes indicative of a heart attack.

Fire Fighting and Sudden Cardiac Death

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]. Among fire fighters, sudden cardiac events have been 

associated with or triggered by alarm response, fire suppression, and heavy exertion during training 

(including physical fitness training) [Kales et al. 2003; Kales et al. 2007; NIOSH 2007]. The FF 

responded to a brush fire where he supported operations for approximately 10 minutes prior to his 

collapse. The FF had considerable experience in wildland fire fighting (he was the Fire Warden) and 

he helped direct hoseline placement for suppression. Immediately before his collapse he had retrieved

50 feet of hose from the engine. NIOSH concludes that the emergency response and the physical 

exertion of operating on the scene may have triggered his heart attack.
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Diabetes Mellitus

NFPA 1582 provides guidance for fire department physicians when evaluating fire fighters with 

diabetes [NFPA 2013]. The standard states that diabetes mellitus that requires insulin compromises the 

member’s ability to safety perform multiple essential job tasks, and a fire fighter with this condition 

should be restricted from duty unless the member meets all of the following criteria:

 is maintained by a physician knowledgeable in current management of diabetes mellitus

 has demonstrated over a period of at least 3 months the motivation and understanding required to 

closely monitor and control blood glucose levels through nutritional therapy and insulin 

administration 

 has a dilated retinal exam by a qualified ophthalmologist or optometrist that shows no higher grade of 

diabetic retinopathy than microaneurysms

 has normal renal function on the basis of a calculated creatinine clearance greater than 60 milliliters 

per minute and absence of proteinuria

 has no autonomic or peripheral neuropathy

 has normal cardiac function without evidence of myocardial ischemia on cardiac stress testing (to at 

least 12 METs by ECG and cardiac imaging)

 has a signed statement and medical records from an endocrinologist or physician knowledgeable in 

the current management of diabetes mellitus as well as the essential job tasks and hazards of fire

fighting that the fire fighter meets the following criteria:

ois maintained on a stable insulin regimen and has demonstrated over a period of at least 3 months 

the motivation and understanding required to closely monitor and control capillary blood glucose 

levels despite varied activity schedules through nutritional therapy and insulin administration

ohas had hemoglobin A1C measured at least four times per year at intervals of 2 to 3 months during 

the past 12 months if the diagnosis of diabetes has been present over 1 year. A hemoglobin A1C 

reading of 8% or greater shall trigger a medical evaluation to determine if a condition exists in 

addition to diabetes that is responsible for the hemoglobin A1C not accurately reflecting average 

glucose levels. 

odoes not have an increased risk of hypoglycemia due to alcohol use or other predisposing factors

ohas had no episodes of severe hypoglycemia in the preceding 1 year, with no more than 1 episode 

of severe hypoglycemia in the preceding 5 years

ois certified not to have a medical contraindication to firefighting training and operations

The FF was an insulin-dependent diabetic who did not meet several of the above criteria for full fire

fighting clearance. The FF did not meet 12 METs on cardiac stress testing, he had renal clearance less 

than 60 milliliters per minute (2014 record), and he did not have a dilated retinal exam. Additionally, 

the FF did not have documentation from an endocrinologist or physician knowledgeable in diabetes

management indicating that he met the criteria regarding diabetes management and fire fighting

training and operations.

Occupational Medical Standards for Structural Fire Fighters

To reduce the risk of sudden cardiac arrest or other incapacitating medical conditions among fire 
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fighters, the National Fire Protection Association (NFPA) developed NFPA 1582, Standard on 

Comprehensive Occupational Medical Program for Fire Departments [NFPA 2013]. This voluntary 

industry standard includes recommendations for medical evaluations of candidates (e.g., 

preplacement), annual evaluations of members, and medical fitness for duty criteria. A medical 

evaluation based on the NFPA 1582 standard would have found that the FF had insulin-dependent 

diabetes mellitus, as well as a history of significant coronary artery disease, including a myocardial 

infarction in 2009, persistence of a modifiable risk factor for acute plaque rupture (tobacco use), lower 

than normal ejection fraction, and diminished functional capacity as revealed by stress 

echocardiography. On the basis of the duration of the stress echocardiogram, his aerobic capacity was 

below 8 METs [Heyward and Gibson 2014], a level at which NFPA 1582 indicates a prescribed 

aerobic fitness program shall be required and restriction from a number of essential job tasks shall be 

considered. The information available to the NIOSH investigator indicates the FF should not have been 

medically cleared for unrestricted fire fighting duty according to NFPA 1582 guidance.

Recommendations

Recommendation #1: Ensure that all fire fighters receive a preplacement and annual medical 

evaluation consistent with NFPA 1582, Standard on Comprehensive Occupational Medical 

Program for Fire Departments, to identify fire fighters at increased risk for cardiovascular disease 

or other conditions.

Discussion: Medical evaluations are performed to determine a fire fighter’s ability to perform duties 

without presenting a significant risk to the safety and health of himself/herself or others. Guidance 

regarding the content and frequency of these evaluations can be found in NFPA 1582 and in the 

International Association of Fire Fighters (IAFF)/International Association of Fire Chiefs (IAFC) Fire 

Service Joint Labor Management Wellness/Fitness Initiative [IAFF, IAFC 2008; NFPA 2013]. 

Following this recommendation will require significant resources and may be difficult to implement. 

Although the FD is not legally required to follow the NFPA standard or the IAFF/IAFC guideline, 

evaluations are highly recommended and steps should be taken to ensure each fire fighter has the 

physical and mental ability to safely perform duties without presenting a significant risk to the fire 

fighter or others. The IAFC recently developed a 4-page “Healthcare Provider’s Guide to Firefighter 

Physicals” to assist community medical providers in providing recommended physical examinations 

and screenings for fire fighters [IAFC 2016]. Additional suggestions for overcoming the financial 

burden of implementing medical examinations for volunteer fire fighters can be found in the Health 

and Wellness Guide for the Volunteer Fire Service developed by the U.S. Fire Administration with 

significant input from the National Volunteer Fire Council. This guide addresses issues specific to 

volunteer fire departments and volunteer fire fighters [USFA 2009].

The FD does not require occupational medical evaluations for candidates or members. The FF received 

a medical examination from a private provider in the fall of 2015, but it is not known if this evaluation 

included all of the recommended occupational components to address his firefighting duties.

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

the physical and mental demands of fire fighting, the personal protective equipment used by fire 
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fighters, and the various components of NFPA 1582.

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

physical and mental 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 

2013]. 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.

The FF underwent medical examination by a private provider in the fall of 2015. According to NFPA 

1582, he had two medical conditions that would preclude a fire fighter from performing as a member 

in emergency operations because of a significant risk to the safety and health of the fire fighter or 

others.

Recommendation #3: Perform an annual physical ability evaluation.

Discussion: NFPA 1500, Standard on Fire Department Occupational Safety and Health Program, 

requires the FD to develop physical performance requirements for candidates and fire fighters who 

engage in emergency operations [NFPA 2013]. Members involved in emergency operations should be 

annually qualified (physical ability evaluation) to meet the physical performance standards. The FD 

does not have physical ability performance requirements for fire fighters, but once developed, the

evaluation could be accomplished as part of the FD monthly training program.

Recommendation #4: 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 USFA Health and Wellness Guide for the Volunteer Fire 

and Emergency Services, and Fire Fighter 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 workrelated injuries and lost work days [Aldana 2001; Stein et al. 2000]. Fire service health promotion 

programs 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 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].
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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 in Cincinnati, Ohio. 

Denise L. Smith, PhD, 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. She is 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,

Cardiac and Medical LODD Investigations Team during this investigation. Wendi Dick, MD, MSPH, 

provided medical consultation and contributed to the report. Dr. Dick leads the Cardiac and Medical 

LODD Investigations Team in Cincinnati.

Disclaimer

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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.