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Executive Summary

On July 14, 2020, a 50-year-old male career firefighter (FF) became disoriented and suffered a sudden 

cardiac arrest while performing extraction work at the scene of a motor vehicle accident. On-scene 

emergency medical services (EMS) immediately initiated cardiopulmonary resuscitation (CPR) and 

provided manual defibrillation. Advanced cardiac life support was provided on-scene and enroute to the 

emergency department (ED). The FF went into full cardiac arrest by a return of spontaneous circulation. 

In the ED, electrocardiograms (EKGs) indicated that the FF was having a myocardial infarction (heart 

attack). The FF was taken to the cardiac catheterization laboratory, but no obstructions were found. The 

FF remained in the hospital in intensive care for six days but never regained consciousness. He suffered 

post-event anoxic brain injury and was pronounced dead on July 20, 2020.

The Medical Examiner’s report listed the cause of death as coronary atherosclerotic disease and 

hypertensive heart disease. National Institute for Occupational Safety and Health (NIOSH) investigators 

concluded that the physical work of the extrication in the heat initiated a sudden cardiac arrest in the FF 

with underlying cardiac disease.

Key Recommendations

• Key Recommendation 1: Ensure that all firefighters receive an annual medical evaluation 

consistent with National Fire Protection Association (NFPA) 1582, Standard on 

Comprehensive Occupational Medical Program for Fire Departments. 

• Key Recommendation 2: Ensure firefighters are cleared for duty by a physician knowledgeable 

about the physical demands of firefighting, the personal protective equipment used by 

firefighters, and the various components of NFPA 1582. 

• Key Recommendation 3: Phase in a mandatory comprehensive wellness and fitness program 

for firefighters.

F2021-03 • July 1, 2021
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Report # F2021-03

The National Institute for Occupational Safety and Health (NIOSH) initiated the Fire Fighter Fatality Investigation and Prevention Program to examine 

deaths of fire fighters in the line of duty so that fire departments, fire fighters, fire service organizations, safety experts and researchers could learn from these 

incidents. The primary goal of these investigations is for NIOSH to make recommendations to prevent similar occurrences. These NIOSH investigations 

are intended to reduce or prevent future fire fighter deaths and are completely separate from the rulemaking, enforcement and inspection activities of any 

other federal or state agency. Under its program, NIOSH investigators interview persons with knowledge of the incident and review available records to 

develop a description of the conditions and circumstances leading to the deaths in order to provide a context for the agency’s recommendations. The NIOSH 

summary of these conditions and circumstances in its reports is not intended as a legal statement of facts. This summary, as well as the conclusions and 

recommendations made by NIOSH, should not be used for the purpose of litigation or the adjudication of any claim.

For further information, visit the program Web site at www.cdc.gov/niosh/fire or call toll free 1-800-CDC-INFO (1-800-232-4636).
Firefighter Suffers Cardiac Arrest at Motor Vehicle Accident—

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F2021-03 • July 1, 2021

Introduction

On July 14, 2020, a 50-year-old male career firefighter (FF) suffered sudden cardiac arrest while 

performing extrication work to rescue a victim of a motor vehicle accident. The FF was admitted to the 

hospital but never regained consciousness, and he died on July 21, 2020. The U.S. Fire Administration 

notified the National Institute for Occupational Safety and Health (NIOSH) of this fatality on August 

July 22, 2020. NIOSH contacted the affected public safety department on September 15, 2020, to 

gather initial information. In July of 2021, a contractor for the NIOSH Firefighter Fatality Investigation 

and Prevention Program (the NIOSH investigator) conducted a series of phone calls and reviewed 

records of the incident.

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

• Fire Chief

• Incident Commander

• Medical examiner

The NIOSH investigator reviewed the following documents:

• Incident report

• Witness statements from Police and Fire

• Emergency medical services (EMS) (ambulance) report

• Hospital emergency department (ED) records

• Autopsy report

Investigation

On July 14, 2020 at 0800 hours, the FF began a 24-hour shift at Station A after working the previous 

24 hours at Station B (as an additional shift) where he ran no calls during his shift. The FF was the 

only person staffing Station A and had run a medical call at approximately 1000 hours. He drove 

Station A’s fire engine to the scene and assisted the ALS crew in loading the patient into the 

ambulance. The medics that he assisted reported that there was nothing out of the ordinary in his 

response or demeanor. At 1623 hours, the FF was dispatched for a motor vehicle accident involving a 
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head-on collision involving two motor vehicles. The temperature was 91°F and 42% humidity 

(weatherunderground.com) and the firefighter responded in full bunker gear.

The FF arrived on scene at 1630 hours, just behind two Sherriff’s Deputies to find an overturned 

vehicle resting near a guardrail with an entrapped driver. The FF carried extrication tools (power unit, 

ram, cutters, spreaders) to the vehicle and also pulled a handline to protect against fire risk. An officer 

arrived on scene within a minute of the FF, and a service truck, also staffed by a single firefighter, 

arrived on-scene at 1633. The officer asked about the FF’s assessment of the scene and assumed 

incident command. The FF removed the rear driver’s side door and was working with the other 

firefighter to continue the extrication when the officer noted that the FF looked exhausted, sweaty, and 

had a flushed appearance. Another firefighter asked the FF if he was okay, and he replied that he 

needed to get to the other side of the vehicle, a response that made little sense given the work that 

needed to be done. The officer told the FF that he needed to sit down and rest. 

At 1633 hours, the ambulance arrived on scene. At approximately 1635 hours, the FF stopped his 

rescue work and walked toward the front of car. After he indicated that he needed to get to the other 

side of the car and then shouted, “I am stuck.” A Sherriff’s Deputy who was nearby and heard the 

claim, ran to his side and found that the FF was not stuck but was shaking uncontrollably. The 

Sherriff’s Deputy and another Deputy saw the FF’s knees begin to buckle and, along with EMS 

personnel, assisted the FF to the ground. As on-scene personnel began to remove his bunker gear, the 

FF became apneic and unresponsive. Ambulance personnel immediately initiated cardiopulmonary 

resuscitation (CPR) and provided oxygen via bag-valve mask at 15 liters per minute (lpm). At 

1638 hours, the FF was placed on a cardiac monitor that showed the FF was in pulseless ventricular 

fibrillation (V-Fib) and he was shocked. The FF took several gasping breaths and returned to full 

cardiac arrest. The FF was rolled onto a backboard and lifted to a stretcher and moved into the 

ambulance. Cardiac medications (epinephrine, etomidate, and midazolam) were administered. The first 

attempt at intubation was unsuccessful, but the second attempt, using King Vision Channeled Blade

and a 7.5 endotracheal tube was successful. Tube placement was confirmed by condensation in tube, 

end tidal carbon dioxide (EtCO2) monitoring, equal breath sounds, and symmetrical chest rise. 

Additional cardiac medications were given and at 1650 hours the ambulance departed the scene for 

the ED. 

At 1652 hours, the FF had a return of spontaneous circulation (ROSC). His vitals were: heart rate (HR) 

= 140 beats per minute (bpm), blood pressure = 59/20 millimeters of mercury (mmHg), oxygen 

saturation 87% (with O2 being administered), and blood glucose of 190 milligrams per deciliter 

(mg/dL). Dopamine was administered. Over the next couple of minutes, the FF remained in sinus 

tachycardia with strong femoral and carotid pulses. At approximately 1700 hours, the FF’s heart 

rhythm returned to ventricular tachycardia (V-Tach), which quickly progressed to V-Fib and the FF 

again became unresponsive. Chest compressions were restarted, and the FF received a second shock. 

Another dose of epinephrine (5th dose) was given. The FF had another ROSC with a sinus rhythm. The 

FF was breathing on his own and fighting against the ET tube, so he was sedated with an additional 

dose of midazolam. At approximately 1708 hours, as the ambulance was arriving at the ED, the FF 

returned to a rhythm of V-Tach. Cardioversion was performed with conversion to sinus tachycardia. 

At 1715 hours, the FF was moved into a trauma room and transferred to a hospital bed.
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In the ED, the FF had additional episodes of ventricular tachycardia and additional shocks were 

provided. A CT of the head found no acute intracranial abnormalities. An echocardiogram showed 

normal left ventricular ejection fraction, but severe concentric left ventricular hypertrophy was noted. 

Blood analysis showed elevated troponin I (0.07 nanograms per milliliter [ng/mL]; normal 

< 0.03 ng/mL) suggestive of cardiac tissue damage. An EKG showed ST elevation (in aVR and V1 

leads) and diffuse ST segment depression. A repeat EKG showed persistent ST elevation in a VR and 

V1 leads and new ST elevation in lead III indicating the FF was having a myocardial infarction (ST 

elevation myocardial infarction, STEMI). After consulting with cardiology, the FF was sent to the 

cardiac catheterization laboratory (Cath lab). The FF underwent left heart catheterization which noted 

mild atherosclerotic disease (30%–40% stenosis) of the left anterior descending (LAD) coronary artery. 

The LAD supplies the anterior area of the heart, which the EKG findings indicated as the site of the 

ischemia. The FF was transferred to intensive care unit where targeted temperature protocols were 

initiated. 

The FF remained in intensive care, on mechanical ventilation for 8 days. On the second day of his 

admission, he developed deep vein thrombosis in the left leg. Despite broad consultation with 

cardiovascular medicine, cardiology, and neurology, the etiology of his cardiac arrest remained unclear. 

During the course of his intensive care treatment, the FF had severe neurological compromise. The 

etiology of the post-event neurological deterioration was also unclear, though it was noted that this 

could have been due to cerebral hypoxia during his cardiac arrest. Repeat head CT revealed severe 

anoxic encephalopathy. On July 21, 2020, at 1520 hours, the FF was pronounced brain dead and life 

support was discontinued.

Medical Findings

The autopsy report listed the cause of death as coronary atherosclerotic disease and hypertensive heart 

disease. Because of the prolonged hospital stay, only a records review and external examination were 

performed by the medical examiner. In the opinion/summary section of the report, the medical 

examiner noted that the FF had a clinical history of hypertension, coronary angiogram evidence of 

coronary atherosclerotic disease, and EKG findings of a myocardial infarction. The FF was not a 

smoker. He was 5’11” and weighed 280 lbs. giving him a body mass index (BMI) of 39. A BMI > 30 

is considered obese [Centers for Disease Control and Prevention 2020]. Hospital records indicated that 

he only had a past medical history of hypertension.

Department

This fire department has 12 stations, each staffed by a single career firefighter who works a 

24 hour on, 48 off shift. Firefighters often work additional shifts outside of this schedule either for 

overtime pay or in trade with another firefighter. There are 15 uniformed members, serving a 

population of over 28,000 residence in an area of approximately 280 square miles. 

The FD requires preplacement medical evaluations for applicants. The evaluations are performed 

by an occupational health clinic that provides the medical evaluations on a contract basis. 

Components of the medical evaluation include the following:

• Complete medical history

• Physical examination (height, weight, blood pressure, pulse, and respiratory rate)
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• Complete blood count 

• Urinalysis

• Urine drug screen

• Audiogram 

• Vision test

• Respirator use questionnaire

• Spirometry 

• Resting EKG

The department does not require annual medical evaluations for members but does perform 

respiratory fit test testing. Members are required to provide medical clearance from a personal 

physician or the City Occupational Health clinic following a serious injury or illness. 

The department does not offer a comprehensive wellness/fitness program as recommended by the 

International Association of Firefighters//International Association of Fire Chiefs Wellness Fitness 

Initiative [IAFF and IAFC 2018]. The FD has some training equipment in each fire station and 

there is a well-equipped gym for county employees near headquarters. The employee insurance 

offered through the department offers a wellness physical.

Discussion 

Sudden Cardiac Events 

Sudden cardiac events are most often caused by myocardial infarction (heart attack) or cardiac arrest 

(fatal arrhythmias). In the United States, atherosclerotic coronary heart disease (also known as 

coronary artery disease or CAD) is the most common risk factor for cardiac arrest and sudden cardiac 

death [Myerburg and Castellanos 2015]. Hypertensive heart disease also increases the risk for sudden 

cardiac events. Sudden cardiac events can be triggered by strenuous work, or emotional stress, both of 

which can precipitate a myocardial infarction or a fatal arrhythmia [Katritsis et al. 2016; Myerberg and 

Castellanos 2015]. Although most individuals suffering an acute myocardial infarction (MIs) have 

obstructive coronary artery disease, approximately 1%–15% of acute MIs occur in the absence of 

obstructive disease and are often termed myocardial infarction with non-obstructive coronary arteries 

(MONICA) [Agewall et al. 2017; Gasior et al. 2020]. Although the phenomenon is not well 

understood, there are several potential mechanisms for MONICA, including myocarditis, coronary 

microvascular spasm, coronary spasm [Gasior et al. 2020]. In this case, the FF was performing 

strenuous work on a hot day which may have served as a triggering event for coronary artery 

vasospasm severe enough to lead to a myocardial infarction as evidenced by EKGs and cardiac 

enzymes in the absence of obstructive atherosclerotic disease. Coronary artery vasospasm does not 

leave any anatomical evidence to be found on autopsy. However, it is possible that a vasospasm 

occurred in the area of the LAD which was already partially occluded (30%–40%) by atherosclerotic 

plaque which may have reduced the blood flow to the anterior portion of the heart enough to result in 

the ischemia noted on the EKG. 
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Hypertensive Heart Disease 

Interactions between genetic factors and hemodynamic factors cause hypertensive heart disease in 

individuals with arterial hypertension [Diamond and Phillips 2005]. Hypertensive heart disease 

includes anatomical and functional changes to the heart and vessels as a consequence of long-standing 

hypertension. Left ventricular hypertrophy (LVH), due to myocyte enlargement with or without 

fibrosis, is a reflection of hypertensive end-organ damage, which can lead to increased ventricular 

mass, abnormal perfusion, congestive heart failure, and arrhythmias [Prisant 2005]. Increased heart 

mass predisposes to fatal arrhythmias [Kahan and Bergfeldt 2005; Tavora et al. 2012]. The FF had a 

reported history of hypertension and the echocardiogram performed in the hospital showed anatomical 

remodeling of the heart consistent with chronic hypertension with concentric hypertrophy. 

Occupational Medical Standards for Structural Firefighters

Nearly half of all firefighter 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 relying on autopsy 

data found that the majority of firefighter duty-related sudden cardiac deaths have coronary artery 

disease and cardiomegaly/left ventricular hypertrophy [Smith et al. 2018] and this is also true for 

young firefighters [Yang et al. 2013]. To reduce the risk of sudden cardiac events or other 

incapacitating conditions among firefighters, the National Fire Protection Association (NFPA) 

developed 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments 

[NFPA 2018]. Guidance in the 1582 Standard recommends annual risk assessment of all firefighters 

≥ 40 years old with a “Heart Risk Calculator” that takes into account age, sex, blood pressure, smoking 

status, etc., to estimate 10-year risk of sudden cardiac events or stroke [ACC/AHA 2018; NFPA 2018]. 

NIOSH offers the following recommendations to help reduce the risk of sudden cardiac events among 

firefighters at this and other fire departments across the country.

Recommendations

Recommendation #1: Ensure that all firefighters 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 2018]. These evaluations are performed to determine a firefighter’s medical 

ability to perform duties without presenting a significant risk to the safety and health of himself/herself 

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

did not have an annual occupational medical evaluation. The FF had been hired in 2018 and but the 

requirement that new hires have a medical evaluation was waived because he had been a firefighter 

in a neighboring county-based FD, and thus he was only required to pass a drug screen before 

being hired. 
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Recommendation #2: Ensure firefighters are cleared for duty by a physician knowledgeable about 

the physical demands of firefighting, the personal protective equipment used by firefighters, and the 

various components of NFPA 1582. 

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

the physical demands of firefighting and the risks that firefighters encounter and should guide, direct, 

and advise members with regard to their health, fitness, and suitability for duty [NFPA 2018]. The 

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

the physiological and psychological demands of firefighting and the environmental conditions under 

which firefighters 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 

firefighters.

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 Firefighters [NFPA 2015], the IAFF/IAFC Fire Service Joint 

Labor Management Wellness/Fitness Initiative (WFI) [IAFF and IAFC 2018], and Firefighter Fitness: 

A Health and Wellness Guide [Schneider 2010]. 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 workdays [Aldana 2001; Stein et al. 2000]. Health promotion programs 

for firefighters 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 department has exercise equipment available to members but does not have a specific 

wellness/fitness program. The county provides health insurance that includes a wellness benefit. 

NIOSH recommends that all firefighters have access to a well-structured health and wellness program 

such as the IAFF/IAFC WFI.

References

ACC/AHA [2018]. Atherosclerotic cardiovascular disease (ASCVD) risk estimator. Washington, D.C.: 

American College of Cardiology/American Heart Association. 

Agewall S, Beltrame JF, Reynolds HR, Niessner A, Rosano G, Caforio ALP, De Caterina R, Zimarino 

M, Roffi M, Kjeldsen K, Atar D. Kaski JC, Sechtem U, Tornvall P, on behalf of the WG on 

Cardiovascular Pharmacotherapy [2017]. ESC working group position paper on myocardial infarction 

with non-obstructive coronary arteries. Eur Heart J 38(3):143–153. 

Aldana SG [2001]. Financial impact of health promotion programs: a comprehensive review of the 

literature. Am J Health Promot 15(5):296–320. 

Blevins JS, Bounds R, Armstrong E, Coast JR [2006]. Health and fitness programming for firefighters: 

does it produce results? Med Sci Sports Exerc 38(5):S454. 

Centers for Disease Control and Prevention (CDC) [2020]. About adult BMI. 
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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. 

Diamond JA, Phillips RA [2005]. Hypertensive heart disease. Hypertens Res 28(3):191–202. 

Gasior P, Desperak A, Gierlotka M, Milewski K, Wita K, Kalarus Z, Fluder J, Kazmierski M, Buszman 

PE, Gasior M, Wojakowski W [2020]. Clinical Characteristics, Treatments, and Outcomes of Patients 

with Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA): results from a 

Multicenter National Registry. J Clin Med 9(9):2779. 

IAFF and IAFC [2018]. The fire service joint labor management wellness-fitness initiative. 

Washington, DC: International Association of Firefighters, International Association of Fire Chiefs. 

Kahan T, Bergfeldt L [2005]. Left ventricular hypertrophy in hypertension: its arrhythmogenic 

potential. Heart 91(2):250–256. 

Katritsis DG, Gersh BJ, Camm AJ [2016]. A clinical perspective on sudden cardiac death. Arrhythm 

Electrophysiol Rev 5(3):177–182. 

Myerburg RJ, Castellanos A [2008]. Cardiovascular collapse, cardiac arrest, and sudden cardiac death.

In: Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J, eds. 

Harrison’s principles of internal medicine. 17th ed. New York: McGraw-Hill. 

NFPA [2015]. NFPA 1583. Standard on health-related fitness programs for fire fighters. Quincy, MA: 

National Fire Protection Association. 

NFPA [2018]. NFPA 1582. Standard on comprehensive occupational medical program for fire 

departments. Quincy, MA: National Fire Protection Association. 

Prisant LM [2005]. Hypertensive heart disease. J Clin Hypertens 7(4):231–238, PMID:15860963. 

Schneider EL [2010]. Firefighter fitness: a health and wellness guide. New York: Nova Science 

Publishers. 

Smith DL, DeBlois JP, Kales SN, Horn GP [2016]. Cardiovascular strain of firefighting and the risk of 

sudden cardiac events. Exerc Sport Sci Rev 44(3):90–97. 

Smith DL, Haller JM, Korre M, Fehling PC, Sampani K, Porto LGG, Christophi CA, Kales SN [2018]. 

Pathoanatomic findings associated with duty-related cardiac death in US firefighters: a case-control 

study. J Am Heart Assoc 7(18):e009446. 

Stein AD, Shakour SK, Zuidema RA [2000]. Financial incentives, participation in employer sponsored 

health promotion, and changes in employee health and productivity: HealthPlus health quotient 

program. J Occup Environ Med 42(12):1148–1155. 

Tavora F, Zhang Y, Zhang M, Li L, Ripple M, Fowler D, Burke A [2012]. Cardiomegaly is a common 

arrhythmogenic substrate in adult sudden cardiac deaths, and is associated with obesity. Pathology 

44(3):187–191. 

Womack JW, Humbarger CD, Green JS, Crouse SF [2005]. Coronary artery disease risk factors in 

firefighters: effectiveness of a one-year voluntary health and wellness program. Med Sci Sports Exerc 

37(5):S385. 
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Yang J, Teehan D, Farioli A, Baur DM, Smith D, Kales SN [2013]. Sudden cardiac death among 

firefighters ≤45 years of age in the United States. Am J Cardiol 112(12):1962–1967. 

Investigator Information

This incident was investigated by the NIOSH Firefighter 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 Human Physiological Sciences and Director of the First Responder Health and 

Safety Laboratory at Skidmore College, where she holds 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 Firefighter Fatality Investigation and 

Prevention Program, Medical LODD Investigations Team, during this investigation. Judith Eisenberg, 

MD, MS, provided medical consultation and contributed to the report. Dr. Eisenberg is Lead for the 

Medical LODD Investigations Team in Cincinnati.

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 Web sites 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 Web sites.