Page i

2016

14

February 3, 2017

Captain Suffers a Heart Attack at a Motor Vehicle Fire and 

Subsequently Dies—Nebraska

Executive Summary

On April 16, 2015, a 42-year-old male volunteer captain (the “Captain”) participated in auto 

extrication training. He set up the extrication tools and performed a door frame cut. The fire 

department was then dispatched to a motor vehicle fire. The Captain drove the tanker to the fire scene. 

He performed fire suppression duties. He then drove a tanker to a nearby town to refill the tanker’s 

water supply. He arrived back at the scene and assisted with overhaul. Then the Captain assisted 

getting a vehicle off the tow-along trailer. After the fire was declared under control, he remained at the 

scene to wash debris from the roadway. As the Captain prepared to leave the scene, he remarked to the 

assistant chief that he did not feel well. The Captain exited the tanker and sat on the rear bumper. He 

related that he was having chest pressure. The Captain then entered the on-scene ambulance. 

Ambulance emergency medical technicians checked the Captain’s vital signs. Feeling nauseated, the 

Captain stepped outside the ambulance and collapsed. He was placed back inside the ambulance. 

Cardiopulmonary resuscitation (CPR) and basic life support began. Air Care was requested and 

advanced life support was provided. The Captain was transported via ground ambulance to the 

hospital’s emergency department (ED). Despite CPR and advanced life support, the Captain was 

pronounced dead.

The death certificate and the autopsy report were completed by the Medical Examiner. The cause of 

death was listed as “acute myocardial infarction” due to “right coronary artery thrombosis” due to 

“atherosclerotic cardiovascular disease.”

Key Recommendations

• Provide preplacement and annual medical evaluations to all fire fighters consistent with 

National Fire Protection Association (NFPA) 1582, Standard on Comprehensive Occupational 

Medical Program for Fire Departments, to identify fire fighters at increased risk for coronary 

heart disease (CHD)

• Ensure that fire fighters are cleared for return to duty by a physician knowledgeable about the 

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

the components of NFPA 1582

The following recommendations would not have prevented the Captain’s death, but NIOSH 

investigators include them to address general safety and health issues:

• Provide fire fighters with medical clearance to wear a self-contained breathing apparatus (SCBA) as 

part of the fire department’s medical evaluation program
Page ii

Captain Suffers an Acute Myocardial Infarction at a Motor Vehicle 

Fire and Subsequently Dies—Nebraska

Report # F2016-14

• Perform candidate and annual physical ability evaluations

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

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. 

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 1

2016

14

February 3, 2017

Captain Suffers a Heart Attack at a Motor Vehicle Fire and 

Subsequently Dies—Nebraska

Introduction

On April 16, 2015, a 44-year old volunteer captain (the “Captain”) died after suffering a fatal heart 

attack at a motor vehicle fire. NIOSH was notified of this fatality on April 20, 2015, by the U.S. Fire 

Administration. NIOSH contacted the affected fire department on April 30, 2015, to gather additional 

information and on July 26, 2016, to initiate the investigation. On August 22, 2016, a safety and 

occupational health specialist from 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

Captain’s spouse

NIOSH personnel reviewed the following documents:

 Fire department standard operating guidelines

Witness statements

 Police report

Ambulance response report

Air care response report

Emergency department report

Death certificate

Autopsy report

 Primary care physician records

Investigation

On April 16, 2015, the Captain arrived at his fire station at about 1850 hours for auto extrication

training. At 1917 hours, the Captain drove the tanker to the training site. He arrived at the training site 

at 1925 hours. Two cars had been placed in a ditch for extrication. The Captain wore full bunker gear, 

helmet, and gloves. He retrieved the extrication tools and placed them at a nearby tool staging area. For 

approximately 7 minutes, he used a scissor tool to cut into the vehicle and assisted others with 

extrication cuts. 

At 1956 hours, the fire department was dispatched to a motor vehicle fire. The Captain drove the 

tanker to the scene, arriving at 2001 hours. A pickup truck (pulling a trailer with a vehicle on the 

trailer) was on fire. No one was trapped but the truck was full of fuel. The Captain and a crewmember 

operated a hoseline to control the fire at the rear of the vehicle. Then they backed up the hoseline to a 
Page 2

Captain Suffers an Acute Myocardial Infarction at a Motor Vehicle 

Fire and Subsequently Dies—Nebraska

Report # F2016-14

safer distance. At 2021 hours, the Captain got a bottle of water to drink and checked on the fire 

apparatus at the scene. At 2030 hours, he notified the fire chief that one of the tankers was low on 

water. The Captain drove that tanker 5 miles to a nearby town to fill the tanker. The Captain completed 

the refill and returned to the scene at 2050 hours. By this time, the fire was under control. 

Crewmembers began overhaul. The Captain assisted in removing the vehicle on the tow trailer. At 

2130 hours, some of the fire apparatus were sent back to the fire station. The Captain remained on the 

scene and assisted in washing debris from the street. He then climbed into the tanker.

At 2200 hours, the Captain notified the assistant chief that he did not feel well. The Captain exited the 

tanker and sat on the rear bumper before entering the ambulance for evaluation. The Captain 

complained of having chest pressure. His vital signs were taken. He had a blood pressure of 128/118 

millimeters of mercury (mmHg) (normal is 120/80), a pulse rate of 126 beats per minute (normal is 60-

80), and his oxygen saturation was at 68% (normal is 95-100%). The Captain became nauseated and 

stepped outside the ambulance. He collapsed and crewmembers placed him on a cot and into the 

ambulance. Dispatch was notified and Air Care was requested at 2206 hours. CPR began and oxygen 

was administered via bag-valve-mask. An automated external defibrillator (AED) was placed. The 

Captain was defibrillated 8 times.

Air Care landed on the scene at 2221 hours. Advanced life support, including an intravenous line, 

cardiac monitoring, and intubation, began. Tube placement was verified by capnography [AHA

2016a]. The cardiac monitor revealed asystole (no heart beat). CPR continued. The ambulance, with 

the Air Care crew, departed the scene at 2233 hours en route to the hospital’s ED. At 2234 hours, the 

cardiac monitor showed sinus rhythm with a weak pulse of 120 beats per minute (sinus tachycardia). 

The Captain tried to start breathing. At 2238 hours the cardiac monitor showed pulseless electrical 

activity and CPR resumed. His heart rhythm reverted to asystole.

The ambulance arrived at the ED at 2246 hours. Inside the ED, advanced life support continued for 13 

minutes more. The Captain was pronounced dead at 2259 hours by the attending physician.

Resuscitation efforts were discontinued.

Medical Findings

The death certificate and the autopsy report were completed by the Medical Examiner. They listed 

“acute myocardial infarction” due to “right coronary artery thrombosis” due to “atherosclerotic 

cardiovascular disease” as the cause of death. Pertinent findings from the autopsy are listed in 

Appendix A.

The Captain had no diagnosed medical conditions. However, three times between 2009 and 2011 his 

blood pressure was elevated (152/94 millimeters of mercury [mmHg], 160/86 mmHg, and 138/100 

mmHg). He was not prescribed any medications. 

Fire Department
Page 3

Captain Suffers an Acute Myocardial Infarction at a Motor Vehicle 

Fire and Subsequently Dies—Nebraska

Report # F2016-14

At the time of the NIOSH investigation, the volunteer fire department consisted of two fire stations

with 23 uniformed personnel. It served 7,000 residents in a geographic area of 275 square miles.

Membership and Training

New fire fighter applicants are required to have a state driver’s license. They must pass a background 

check. The applicant must list any disability or handicap on the application. This determines whether 

the applicant may become an interior structural fire fighter, external support fire fighter, or a nonemergency response member. New members are on probation for 6 months. They receive in-house 

basic fire fighter training. The fire department offers training twice monthly. The state does not have 

minimum training standards. The Captain was certified as a Fire Fighter I, First Responder, and in 

technical rescue. He was promoted to Captain in 2012 and had 8 years of fire fighting experience.

Preplacement and Periodic Medical Evaluations/Return to Work 

Medical Evaluations

Preplacement and periodic medical evaluations are not required by the fire department. If a member is 

injured on duty, clearance for return to duty is required. The clearance is provided by the member’s 

primary care phsycian, who provides the clearance to the fire chief. The fire chief makes the final 

determination regarding return to duty. If a member has a major illness and cannot respond to 

emergencies or take part in other fire department activities, the member’s primary care physician must 

provide medical clearance for return to duty. The clearance is provided to the fire chief who makes the 

final decision about return to duty.

Wellness/Fitness Programs

The fire department does not have a wellness/fitness program. Candidate and annual physical ability 

tests are not required. The Captain exercised by riding a bicycle for about 30 minutes at least three 

times per week.

Discussion

Coronary Heart Disease and Sudden Cardiac Events

In the United States, atherosclerotic CHD 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. 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 2016b; 

NHLBI 2016]. The Captain had one non-modifiable risk factor (male gender) and one modifiable risk 

factor (obesity).

Coronary artery narrowing by atherosclerotic plaques occurs over many years, typically decades 

[Libby 2008]. 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 
Page 4

Captain Suffers an Acute Myocardial Infarction at a Motor Vehicle 

Fire and Subsequently Dies—Nebraska

Report # F2016-14

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

atherosclerotic plaques. Establishing a recent (acute) heart attack requires characteristic 

electrocardiographic changes, elevated cardiac enzymes, or a coronary artery thrombus. In this case, an

acute coronary artery thrombus was revealed at autopsy. Additional evidence of CHD revealed at 

autopsy included an old, healed heart attack with adjacent changes compatible with early ischemia.

Left Ventricular Hypertrophy (LVH)

On autopsy, the Captain was found to have LVH, which increases the risk for sudden cardiac death 

[Levy et al. 1990]. Hypertrophy of the heart’s left ventricle is a relatively common finding among 

individuals with long-standing hypertension, a heart valve problem, or chronic cardiac ischemia 

(reduced blood supply to the heart muscle) [Siegel 1997]. Although the Captain had three instances of 

elevated blood pressure readings, he was not diagnosed with hypertension. He did not have heart valve 

problems. The autopsy did reveal early ischemia from the old heart attack. Therefore, his LVH was 

probably the result of ischemia. Whether undiagnosed hypertension was present and contributed to his 

death is uncertain.

Physiological Stress of Firefighting

Heart attacks and sudden cardiac death can be triggered by heavy physical exertion [Mittleman et al. 

1993; Willich et al. 1993; Albert et al. 2000]. Among fire fighters, sudden cardiac events have been 

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

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

auto extrication training then responded to a vehicle fire where he assisted with fire suppression and 

cleanup while wearing full bunker gear. These activities expended about 9 metabolic equivalents, 

which is considered heavy physical activity [Ainsworth et al. 2011].

Occupational Medical Standards for Structural Fire Fighters

To reduce the risk of sudden cardiac arrest or other incapacitating medical conditions among fire 

fighters, the National Fire Protection Association developed NFPA 1582, Standard on Comprehensive 

Occupational Medical Program for Fire Departments [NFPA 2013a]. This voluntary industry standard 

provides the components of a preplacement and annual medical evaluation and medical fitness for duty 

criteria.

Recommendations

Recommendation #1: Provide preplacement and annual medical evaluations to all fire fighters in 

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

Fire Departments, to identify fire fighters at increased risk for CHD.

Discussion: Guidance regarding the content and frequency of these medical 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 2013a]. These evaluations are performed to determine fire fighters’ medical ability to 

perform duties without presenting a significant risk to the safety and health of themselves or others.

Following this recommendation will require significant resources and may be difficult to implement. In 
Page 5

Captain Suffers an Acute Myocardial Infarction at a Motor Vehicle 

Fire and Subsequently Dies—Nebraska

Report # F2016-14

addition, the fire department has no legal obligation to follow the NFPA standard or the IAFF/IAFC 

guideline.

Recommendation #2: Ensure that fire fighters are cleared for return to 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: NFPA 1582 requires that the fire department designate a physician responsible for guiding, 

directing, and advising the 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 fire 

department positions to understand the physiological and psychological demands of fire fighters and 

the environmental conditions under which they must perform, as well as the personal protective 

equipment they must wear during various types of emergency operations. Currently, the member’s 

primary care physician provides medical clearance for return to work. It is unclear if fire fighters’ 

personal physicians are familiar with the recommendations of NFPA 1582 [NFPA 2013a]. 

The following recommendations would not have prevented the Captain’s death, but NIOSH 

investigators include them to address general safety and health issues:

Recommendation #3: Provide fire fighters with medical clearance to wear SCBA as part of the fire 

department’s medical evaluation program.

Discussion: The Occupational Safety and Health Administration (OSHA) Revised Respiratory 

Protection Standard requires employers to provide medical evaluations and clearance for employees 

using respiratory protection [29 CFR 1910.134]. These clearance evaluations are required for private 

industry employees and only for public employees in states operating OSHA-approved state plans. 

Because Nebraska does not operate a state OSHA plan [OSHA 2016], the fire department is not 

required to provide medical evaluations for employees using respirators. However, we recommend 

voluntary compliance with this recommendation to improve fire fighter health and safety.

Recommendation #4: Perform candidate and annual physical ability evaluations.

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

requires the fire department to develop physical performance requirements for candidates and members 

who engage in emergency operations [NFPA 2013b]. Members who engage in emergency operations 

must be annually qualified (physical ability test) as meeting these physical performance standards for 

structural fire fighters [NFPA 2013b]. Once developed by the fire department, the annual evaluation 

could be performed as part of the annual training program.

Recommendation #5: 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 the IAFF/IAFC Fire Service 

Joint Labor Management Wellness/Fitness Initiative, the National Volunteer Fire Council Health and 
Page 6

Captain Suffers an Acute Myocardial Infarction at a Motor Vehicle 

Fire and Subsequently Dies—Nebraska

Report # F2016-14

Wellness Guide, in Firefighter Fitness: A Health and Wellness Guide, and in NFPA 1583, Standard on 

Health-Related Fitness Programs for Fire Fighters, [IAFF, IAFC 2008; USFA 2009; Schneider 2010; 

NFPA 2015]. 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 [Pelletier 2009; Baicker et al. 2010]. Fire service health promotion programs have been shown to 

reduce coronary artery disease risk factors and improve fitness levels, with mandatory programs 

showing the most benefit [Dempsey et al. 2002; Womack et al. 2005; Blevins et al. 2006; Poston et al. 

2013]. A study conducted by the Oregon Health and Science University reported a savings of more 

than $1 million for each of four large fire departments implementing the IAFF/IAFC wellness/fitness 

program compared to four large fire departments not implementing a program. These savings were 

primarily due to a reduction of occupational injury/illness claims with additional savings expected 

from reduced future nonoccupational healthcare costs [Kuehl et al. 2013].

The fire department does not offer a wellness/fitness program and exercise equipment is not available 

in the fire stations. Given the fire department’s structure, the National Volunteer Fire Council program 

would be applicable [USFA 2009]. NIOSH would recommend a formal, mandatory wellness/fitness 

program to ensure all members receive the benefits of a health promotion program.

References

AHA [2016a]. Part 7: Adult advanced cardiovascular life support. 2015 American Heart Association 

Guidelines Update for cardiopulmonary resuscitation and emergency cardiovascular care. Dallas, TX: 

American Heart Association. https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines2/part-7-adult-advanced-cardiovascular-life-support/.

AHA [2016b]. Understand your risk of heart attack. Dallas, TX: American Heart Association. 

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

stand-Your-Risk-of-Heart-Attack_UCM_002040_Article.jsp.

Ainsworth BE, Haskell WL, Herrmann SD, Meckes N, Bassett DR Jr, Tudor-Locke C, Greer JL, 

Vezina J, Whitt-Glover MC, Leon AS [2011]. Compendium of physical activities: a second update of 

codes and MET values. Med Sci Sports Exerc 43(8):1575–1581, http://dx.doi.org/

10.1249/MSS.0b013e31821ec. 

Albert CM, Mittleman MA, Chae CU, Lee IM, Hennekens CH, Manson JE [2000]. Triggering of 

sudden death from cardiac causes by vigorous exertion. N Engl J Med 343(19):1355–1361, 

http:dx.doi.org/10.1056/NEJM200011093431902.

Baicker K, Cutler D, Song Z [2010]. Workplace wellness programs can generate savings. Health 

Affairs 29(2):304–311, http://dx.doi.org/10.1377/hlthaff.2009.0626.

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

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

CFR. Code of Federal Regulations. Washington, DC: U.S. Government Printing Office, Office of the

Federal Register. https://www.gpo.gov/fdsys/browse/collectionCfr.action?collectionCode=CFR.
Page 7

Captain Suffers an Acute Myocardial Infarction at a Motor Vehicle 

Fire and Subsequently Dies—Nebraska

Report # F2016-14

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.

IAFF, IAFC [2008]. The fire service joint labor management wellness/fitness initiative. 3rd ed. 

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

Kales SN, Soteriades ES, Christoudias SG, Christiani DC [2003]. Firefighters and on-duty deaths from 

coronary heart disease: a case control study. Environ health: a global access science source. 2:14. 

http://www.ehjournal.net/content/2/1/14. 

Kales SN, Soteriades ES, Christophi CA, Christiani DC [2007]. Emergency duties and deaths from 

heart disease among fire fighters in the United States. N Engl J Med 356(12):1207–1215, 

http://dx.doi.org/10.1056/NEJMoa060357.

Kuehl KS, Elliot DL, Goldberg L, Moe EL, Perrier E, Smith J [2013]. Economic benefit of the 

PHLAME wellness programme on firefighter injury. Occup Med 63(3):203–209, http://dx.doi.org/

10.1093/occmed/kqs232.

Levy D, Garrison RJ, Savage DD, Kannel WB, Castelli WP [1990]. Prognostic implications of 

echocardiographically determined left ventricular mass in the Framingham Heart Study. N Engl J Med 

323(24):1706–1707.

Libby P [2008]. The pathogenesis, prevention, and treatment of atherosclerosis. 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, pp. 1501–1509.

Meyerburg 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, pp. 1707–1713.

Mittleman MA, Maclure M, Tofler GH, Sherwood JB, Goldberg RJ, Muller JE [1993]. Triggering of 

acute myocardial infarction by heavy physical exertion. N Engl J Med 329(23):1677–1683.

NFPA [2013a]. Standard on comprehensive occupational medical program for fire departments. 

Quincy, MA: National Fire Protection Association. NFPA 1582.

NFPA [2013b]. Standard on fire department occupational safety and health program. Quincy, MA: 

National Fire Protection Association. NFPA 1500.

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

Protection Association. NFPA 1583.

NHLBI [2016]. Who is at risk for coronary artery disease? National Heart, Lung, and Blood Institute. 

http://www.nhlbi.nih.gov/health/health-topics/topics/cad/atrisk.html. 

NIOSH [2007]. NIOSH alert: preventing fire fighter fatalities due to heart attacks and other sudden 

cardiovascular events. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for 

Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS 

(NIOSH) Publication No. 2007-133, http://www.cdc.gov/niosh/docs/2007-133/.
Page 8

Captain Suffers an Acute Myocardial Infarction at a Motor Vehicle 

Fire and Subsequently Dies—Nebraska

Report # F2016-14

OSHA (Occupational Safety and Health Administration) [2016]. State occupational safety and health 

plans. http://www.osha.gov/dcsp/osp/index.html. 

Pelletier KR [2009]. A review and analysis of the clinical and cost‐effectiveness studies of 

comprehensive health promotion and disease management programs at the worksite: update VII 2004–

2008. J Occup Environ Med 51(7):822–837, http://dx.doi.org/10.1097/JOM.0b013e3181a7de5a.

Poston WSC, Haddock CK, Jahnke SA, Jitnarin N, Day RS [2013]. An examination of the benefits of 

health promotion programs for the national fire service. BMC Pub Health 13(1):805–819,

http://dx.doi.org/10.1186/1471-2458-13-805.

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

Publishers.

Siegel RJ [1997]. Myocardial hypertrophy. In: Bloom S, ed. Diagnostic criteria for cardiovascular 

pathology acquired diseases. Philadelphia, PA: Lippencott-Raven, pp. 55–57.

USFA [2009]. Health and wellness guide for the volunteer fire and emergency services. Emmitsburg, 

MD: Federal Emergency Management Agency; United States Fire Administration. Publication No. 

FA-321, https://www.usfa.fema.gov/downloads/pdf/publications/fa_321.pdf.

Willich SN, Lewis M, Lowel H, Arntz HR, Schubert F, Schroder R [1993]. Physical exertion as a 

trigger of acute myocardial infarction. N Engl J Med 329(23):1684–1690.

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.

Investigator Information

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

Program, Cardiovascular Disease Component in Cincinnati, Ohio. Mr. Tommy Baldwin (MS) led the 

investigation and co-authored the report. Mr. Baldwin is a Safety and Occupational Health Specialist, a 

National Association of Fire Investigators (NAFI) Certified Fire and Explosion Investigator, an 

International Fire Service Accreditation Congress (IFSAC) Certified Fire Officer I, and a former Fire 

Chief and Emergency Medical Technician.

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. All web addresses referenced 

in this document were accessible as of the publication date.
Page 9

Captain Suffers an Acute Myocardial Infarction at a Motor Vehicle 

Fire and Subsequently Dies—Nebraska

Report # F2016-14

Appendix A

Autopsy Findings

Coronary artery disease

o Total (100%) occlusion of the right coronary artery by a thrombus (blood clot)

o Moderate (50%) focal narrowing of the left anterior descending coronary artery

Hypertensive heart disease

o Cardiomegaly (heart weighed 480 grams [g])

• predicted normal weight based on body length ranges between 330 g and 410 g [Zeek 1942]

• Predicted normal weight as a function of sex, age, and body weight is 421 g (ranges 

between 319 g and 556 g) [Silver and Silver 2001]

o Left Ventricular Hypertrophy

• Left ventricle and septum thickened (1.6 centimeters [cm] and 1.5 cm respectively)

o Normal at autopsy is 0.76–0.88 cm [Colucci and Braunwald 1997] 

o Normal by echocardiographic measurement is 0.6–1.0 cm [Connolly and Oh 2012]

o Region of scarring in the posterior left ventricle, with areas of adjacent mottling consistent with 

a remote (old) myocardial infarction of the posterior left ventricle

o Microscopic area of cardiac myocytes are slightly thin and wavy with increased eosinophilia 

Cardiac valves were normal

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

Blood tests for drugs and alcohol were negative.

REFERENCES

Colucci WS, Braunwald E [1997]. Pathophysiology of heart failure. In: Braunwald, ed. Heart disease. 

5th ed. Philadelphia, PA: W.B. Saunders Company, p. 401.

Connolly HM, Oh JK [2012]. Echocardiography. In: Bonow RO, Mann DL, Zipes DP, Libby P, 

Braunwald E, eds. Heart disease: a text of cardiovascular medicine. 9th ed. Vol. 1. Philadelphia, PA: 

Elsevier Saunders, p. 216.

Silver MM, Silver MD [2001]. Examination of the heart and of cardiovascular specimens in surgical 

pathology. In: Silver MD, Gotlieb AI, Schoen FJ, eds. Cardiovascular pathology. 3rd ed. Philadelphia, 

PA: Churchill Livingstone, pp. 8–9.

Zeek PM [1942]. Heart weight I: the weight of the normal human heart. Arch Pathol 34:820, 

http://dx.doi.org/10.1016/S0002-8703(43)90504-6.