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Executive Summary

On April 21, 2020, a 43-year-old male career fire engine operator (FEO) died during a physical fitness training 

run while on-duty. The engine company consisted of a four-person crew, including a lieutenant (LT), the FEO 

and two firefighters. On the day of the incident, the FEO arrived at his regular single engine company fire 

station. The crew began their shift by conducting ladder inspections and training, followed by flushing the 

engine pump just prior to dinner. At approximately 1830 hours, the crew began physical fitness training that 

included weight training, pull-ups, stationary bicycling, and running. 

As the crew participated in various types of physical fitness training at the station, the FEO chose to run 

several laps around the fire station neighborhood by himself. Crew members stated that was a change for the 

FEO, as he normally chose weightlifting and did not typically run for his physical fitness training. 

As the LT was doing his own workout, he could see the FEO outside as he passed the fire station. After a few 

laps the LT noticed the FEO had not passed the fire station as he expected, so he looked down the street and 

witnessed the FEO fall to the ground. The LT called for the two firefighters working out to assist checking on 

the FEO. They found him unresponsive with his jaw clenched and arms in rigid extension. The LT 

immediately called fire dispatch at approximately 1915 and requested an ambulance for a “firefighter down.” 

The transporting ambulance arrived at 1917 hours and assisted the station crew initiate advanced life support 

(ALS). ALS efforts were continued en-route to the nearest hospital, located two blocks away. On arrival to the 

Emergency Department, the FEO became pulseless. Resuscitation efforts were continued but were 

unsuccessful and the FEO was pronounced dead at 1952 hours. The autopsy revealed the cause of death to be 

exercised induced pulmonary hemorrhage (EIPH).

Key Recommendations

NIOSH investigators offer the following recommendations to prevent similar fatal events, and to address 

general health and safety issues among firefighters at this and other fire departments across the country. 

Key Recommendation 1: Consider including information on training intensity and EIPH on physical fitness 

training materials

Key Recommendation 2: Provide annual medical evaluations consistent with National Fire Protection 

Association (NFPA) 1582 Standard on Comprehensive Occupational Medical Program for Fire 

Departments, which includes an evaluation of aerobic capacity in all individuals prior to engagement in any 

strenuous physical activity by conducting an exercise stress test [NFPA 2018].

F2021-01 • January 26, 2022
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Key Recommendation 3: Implement a mandatory wellness and fitness program for fire department members 

consistent with NFPA 1583 Standard on Health-Related Fitness Programs for Fire Departments Members 

and the IAFF/IAFC Wellness-Fitness Initiative, which includes determining intensity of exercise 

[IAFF/IAFC 2018; NFPA 2015].

Key Recommendation 4: Consider methods to stay in communication during physical exercise such as 

carrying a department radio or exercising in pairs when possible.

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 Dies from Exercise Induced Pulmonary Hemorrhage 

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F2021-01 • January 26, 2022

Introduction

On April 21, 2020, a 43-year-old male career firefighter suffered a medical emergency while 

participating in a physical fitness run and died. The U.S. Fire Administration notified the National 

Institute for Occupational Safety and Health (NIOSH) of this fatality on April 24, 2020. NIOSH 

contacted the affected department to gather additional information and initiate the investigation. 

A medical officer, investigator, and a firefighter safety specialist from the NIOSH Fire Fighter Fatality 

Investigation and Prevention Program (FFFIPP) conducted the investigation.

During the investigation, the NIOSH investigators interviewed the following agency personnel:

• Assistant Chief

• Crew members

• Department physician

• Family member

NIOSH personnel reviewed the following documents:

• Fire department standard operational procedures

• Facility incident reports

• Department medical policies

• Emergency medical service (ambulance) report

• Autopsy and toxicology reports

• Agency physician records

Fire Department

The department is a full-service municipal fire department with 34 fire stations, 918 career firefighters 

and 240 civilian employees and has an ISO (Insurance Services Offices) Class 1 rating. The 

department serves a population of approximately 680,000 over 260 square miles and responds to more 

than 70,000 calls annually. The calls include fires, medical emergencies, and hazardous materials 

incidents within the city, as well as paramedic and ambulance transport to the community. The 
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department also responds to water, mountain, and technical rescues. In addition, the department 

responds to the county and neighboring military base through a mutual aid agreement.

Employment and Training

The hiring process consists of:

• Written examination-minimum score of 70% to advance

• Physical agility test-the department utilizes the candidate physical ability test (CPAT)

• Background investigation

• Fire department oral interview

• Physical examination-City appointed physician will perform exam to the standards of the 

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

Medical Program for Fire Departments. 

The departments physical fitness training policy allows for one hour of physical training per 

24-hour shift.

Preplacement/Periodic/Return to Work Medical Evaluation

Preplacement

After selection is made by the fire chief, applicants are given a conditional offer of employment and 

scheduled for a physical exam by a city appointed physician to determine whether or not an applicant 

is able to perform the tasks required of a firefighter. Additionally, applicants will be screened for drugs. 

All physical examinations will be performed to the standards of NFPA 1582: Standard on 

Comprehensive Occupational Medical Program for Fire Departments [NFPA 2018].

Periodic

All personnel complete an annual physical exam administered by a third-party provider. Operations 

personnel must complete their annual physical by October 31st of each year. To meet this goal, a 

minimum of 10% of line personnel will complete their physical each month. Personnel assigned to a 

40-hour position will complete their annual physical in November and December of each year. 

Personnel will coordinate with their respective battalion chief or division head when scheduling their 

physicals. The only exceptions to this policy will be for personnel on long-term protected leave.

Return to Work

After a “lost time” injury, a physician must provide a statement that the employee has sufficiently 

recovered to return to duty. An employee who has returned to work after a “lost time” injury may not 

take additional days off because of the injury without certification by a doctor of a continuing 

disability.

Wellness/Fitness Programs

The Wellness/Fitness Initiative of the department has incorporated the fitness initiative outlined in 

NFPA 1500. The program recognizes that at least three hours per week must be dedicated to a fitness 
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routine for the employee to be productive in their fitness effort. To accomplish this, employees who 

work the 56-hour schedule will exercise for at least one hour per shift. All other uniformed employees 

may organize their workout times into a format conducive to their work schedule. The exercise 

program will consist of: 

• a proper warm-up 

• stretching to improve flexibility 

• cardiovascular exercise to improve endurance 

• weight-training to improve strength 

• a proper cool-down

Investigation

The station is in the central part of a city and serves a combination of residential, commercial, and 

institutional districts. Daily staffing for the engine company at this station includes a lieutenant (LT), 

fire engine operator (FEO), and two firefighters. A 43-year-old male career firefighter arrived at the 

station as scheduled for his regular 24-hour shift on April 21, 2020. He was permanently assigned as 

the driver/operator (also known as the FEO), for the engine at the single company fire station.

The crew began their 24-hour shift at 1145 hours. According to the fire department incident report 

activities for the crew began at 1415 hours with the monthly drill and inspection of the ground ladders, 

followed by refresher training for the firefighters on pump operations and flushing the pump. The crew 

had dinner at 1700 hours. The crew had not responded to any emergency calls since they started their 

shift. 

At approximately 1830 hours the crew began their physical fitness training. According to Weather 

Underground, the ambient temperature at 1856 was 86 degrees Fahrenheit [Weather Underground nodate]. The FEO chose to run around the neighborhood, while the LT and firefighters did weight 

training, pull-ups, and bicycling in the station’s indoor gym. The crew noted that the FEO normally 

chose to weightlift for physical training, and they had not seen him run for years while at the station. 

The FEO began his run going east from the fire station for one block on a slight incline, then made a 

left running north for two blocks on a slight decline, made another left turn running west for one block 

on a decline, and made a final left turn running south for two blocks on an incline back to the fire 

station. The course was essentially a rectangle, beginning and ending at the fire station for a total 

distance of 0.33 miles. The department’s investigation found that the FEO had almost completed 

11 laps around the two-block area for a total distance of approximately 3.6 miles. Each lap had an 

elevation gain/loss was +57.2 feet (ft), -57.2 ft with a maximum slope of 24.7% and average slope of 

+3.9% and -4.9% (see Figure 1).
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Figure 1. The physical training run path (marked in blue). Photo adapted from Google Earth.

As the LT was doing his own physical training, he noticed the FEO as he ran past the station 

completing a lap. After several laps, the LT realized that the FEO was taking longer than normal to 

pass the station again and decided to step out and look for him down the street. At approximately 

1911 hours he noticed the FEO about 40 yards from the station and witnessed him slowly drop to the 

ground and lay supine on the sidewalk. The LT called for the other firefighters to help him check on 

the FEO. On initial examination, his teeth were clenched, his arms in full extension, his head turned to 

the right and eyes looking to the right. The LT immediately ran back to the station and contacted fire 

dispatch from the fire station phone. The LT requested an ambulance for a “firefighter down”, while 

the crew took vitals, monitored breathing and maintaining the FEO’s airway. The LT returned from 

calling for assistance with an airway bag and medical bag. The crew started an intravenous (IV) line 

and ventilated him with a bag valve mask (BVM). There was no apparent upper airways obstruction. 

The firefighter ventilating with the BVM noted that there was a lot of pressure, so they did a head tilt 

chin lift to improve the airway. 

The transport ambulance, a fire department rescue ambulance unit, arrived at approximately 

1917 hours at the station. The ambulance crew assisted the LT and two firefighters to load the FEO 

into the rescue ambulance. ALS care was continued as they responded to the closest hospital 

approximately one-half mile away. Upon patient transfer at the hospital, the FEO became pulseless. 

Cardiopulmonary resuscitation (CPR) was unsuccessful and he was pronounced dead at 1952 hours.

Medical Findings

The most recent physical for the FEO was in February of 2019. He was 78” tall and weighed 

253 pounds resulting in a body mass index (BMI) of 30.0. His resting blood pressure was 

122/77 millimeters of mercury (mmHg) and resting pulse was 80 beats per minutes (bpm). His BMI 

was in the borderline obese range and his blood pressure was normal (Table 1).
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Table 1. Cardiovascular (CVD) Risk Factors (RFs) 

Risk Factor Interpretation Category Guidelines 

Systolic BP1 Normal

Elevated

Stage 1 Hypertension 

Stage 2 Hypertension 

< 120 mmHg 

120–129 mmHg 

130–139 mmHg 

≥ 140 mmHg 

Diastolic BP1 Normal

Elevated

Stage 1 Hypertension 

Stage 2 Hypertension 

< 80 mmHg 

> 80 mmHg 

80–89 mmHg 

≥ 90 mmHg 

Total 

Cholesterol2

Desirable

Borderline High 

High

< 200 mg/dL 

200–239 mg/dL 

≥ 240 mg/dL 

HDL2 Low

High (Desirable)

< 40 mg/dL 

≥ 60 mg/dL 

LDL2 Optimal

Above normal 

Borderline high 

High

< 100 mg/dL

100–129 mg/dL 

130–159 mg/dL 

> 160 mg/dL 

Triglycerides3 Normal

Hypertriglyceridemia

Severe hypertriglyceridemia 

> 175mg/dL

175–499mg/dL 

≥ 500mg/dL 

Blood 

Glucose4

Normal

Prediabetes

Diabetes

< 100 mg/dL

100–125 mg/dL 

≥ 126 mg/dL 

BMI5 Underweight 

Normal weight 

Overweight 

Obesity

< 18.5 kg/m2

18.5–24.9 kg/m2

25–29.9 kg/m2

≥ 30 kg/m2

Note: References for Table 1: 1Whelton et al. 2017; 2Kratz et al. 2004; 3Grundy et al. 2019; 

4

ADA 2014; 5CDC 2020.

The February 2019 medical evaluation also included an exercise stress test during which the FEO 

exercised for 7:02 minutes achieving a work level of 11.80 max metabolic equivalents (METs). His 

resting heart rate of 100 bpm rose to a maximal heart rate of 173 bpm. This value represents 97% of 

the maximal, age predicted heart rate. His resting blood pressure of 122/77 mmHg rose to 
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134/95 mmHg. The exercise was stopped when the FEO achieved his target heart rate of 171 bpm. 

The overall impression was a normal stress test. Due to COVID-19 issues, physicals for fire 

department employees were delayed in 2020 and the FEO was scheduled for a physical the week 

following his death.

Cause of Death

According to the death certificate, the medical examiner listed the FEO’s cause of death as EIPH.

Discussion

EIPH is a rare syndrome that can occur following intense physical activity and is where the air sacs of 

the lungs fill with blood and impede oxygen delivery. It is important to distinguish EIPH from diffuse 

alveolar hemorrhage (DAH) caused by chronic heart disease (heart failure or mitral valve problems), 

where bleeding occurs from high venous pressure that causes stress failure of the capillaries in the 

lungs. [Marak et al. 2013; Saha and Chong 2021; Sakamoto et al. 2020]. EIPH is similar to exerciseinduced pulmonary edema, described in swimmers for decades, though cases have been described in 

runners as well. It is most studied in the veterinary literature as occurring in thoroughbred horse racing, 

where racehorses have leakage of fluids into their lungs following an intense race [Hinchcliff et al. 

2015]. Studies of athletes with this condition show that following intense exercise, there are increased 

concentrations of red blood cells and proteins in the lungs, indicating a problem with the exchange of 

gas between the air and the bloodstream [Ghio et al. 2006; Hopkins et al. 1997; West 2004].

The blood-gas barrier of the human lung is fragile, and so if there is any structural changes or damage 

to the capillary walls this can cause increase leakage of fluid into the air sacs. Studies in both humans 

and animals show that there can be increased capillary pressures during intense exercise because of the 

higher pressures that are needed in the left ventricle of the heart. Tests of the heart and lungs in elite 

athletes after they exercise can show more red cells in the lungs even while their lungs are otherwise 

normal [Diwakar and Schmidt 2014; Spencer et al. 2018]. 

The majority of reported cases of exercise-induced pulmonary hemorrhage recover with temporary 

lack of oxygen or bleeding into the lung that can be treated immediately with oxygen and other 

emergency support. However, on rare occasions this condition can be severe and cause death even 

when proper emergency measures are taken. It is not known why some individuals can have very 

severe exercise-induced pulmonary hemorrhage, and others survive. It appears from studies that EIPH 

in athletes happens after intense and/or maximal exercise [Hohmann et al. 2018; McKechnie et al. 

1979; Weiler-Ravell et al. 1995], but research is still ongoing to find the exact medical risk factors that 

can help predict why this occurs. At this time, there are currently no tests of the lungs or heart that can 

screen for this condition or predict whether intense exercise will trigger the lung problem in specific 

individuals.

Recommendations

Since it is not yet known what medical tests or examinations can reliably predict who may develop 

EIPH, NIOSH investigators can only offer the following recommendations to address general health 

and safety issues among fire fighters at this and other fire departments across the country.
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Recommendation #1: Consider including information on EIPH on physical fitness training 

materials and/or conducting an in-service on this rare medical condition.

Discussion: While EIPH is a relatively rare condition, firefighters should be aware that this can cause 

sudden collapse and the need for emergency response. The presence of pink frothy secretions or blood 

may indicate lung hemorrhage and require immediate intubation and supplemental oxygen, followed 

by in-hospital medical treatment. In many cases, individuals can recover from EIPH without 

permanent organ damage.

Recommendation #2: Provide annual medical evaluations consistent with NFPA 1582, which 

includes an evaluation of aerobic capacity in all individuals prior to engagement in any strenuous 

physical activity by conducting an exercise stress test. Testing shall be conducted using maximal or 

sub-maximal protocol. (Appendix A).

Discussion: In this case, the department does perform annual medical evaluations consistent with 

NFPA 1582. It is important to note that maximal annual exercise stress test is recommended to be 

performed by qualified medical personnel conducted in a medical care setting. It is unknown if the 

annual exercise stress test would have identified any anomalies for the FEO. The FEO’s last exercise 

stress indicated a VO2 max of 11.80. NFPA 1582 states that individuals with levels below 12 MET’s 

shall receive counseling to improve his/her fitness. Individuals below 10 MET’s shall participate in an 

aerobic fitness program and individuals below 8 MET’s shall be prescribed an aerobic fitness program 

and the authority having jurisdiction shall be advised to consider restriction from essential job tasks.

Recommendation #3: Implement a mandatory wellness and fitness program for fire department 

members consistent with NFPA 1583 and the IAFF/IAFC Wellness-Fitness Initiative, while being 

mindful of the intensity of exercise [IAFF/IAFC 2018; NFPA 2015]. Consider restricting maximal 

effort exercise to non-workdays as work-related strenuous tasks may place firefighters into higher 

risk category for EIPH in addition to physical fitness training done during work hours.

Discussion: It is important to note that studies indicate EIPH typically follows intense exercise. When 

determining the proper intensity of exercise, the following must be considered:

1. Level of fitness

2. Medications that affect heart rate

3. Environmental conditions

4. Risk of cardiovascular or orthopedic injury

5. Individual objectives and preferences

6. Job specificity

NFPA 1583 states that how hard an individual exercises can be determined by monitoring exercise 

heart rate, perceived exertion, or caloric expenditure. The American College of Sports Medicine 

(ACSM) recommends that fire department members exercise at a heart rate between 70 and 90 percent 

of maximal heart rate or 60–80 percent of ones VO2 Max [Riebe et al. 2018]. 

For moderate-intensity physical activity, your target heart rate should be between 64% and 76% of 

your maximum heart rate. You can estimate your maximum heart rate based on your age. To estimate 
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your maximum age-related heart rate, subtract your age from 220. For example, for a 43-year-old 

person, the estimated maximum age-related heart rate would be calculated as 220 – 43 years = 

177 bpm. The 64% and 76% levels would be:

• 64% level: 177 x 0.64 = 113 bpm, and

• 76% level: 177 x 0.76 = 134 bpm

This shows that moderate-intensity physical activity for a 43-year-old person will require that the 

heart rate remain between 113 and 134 bpm during physical activity.

For vigorous-intensity physical activity, your target heart rate should be between 77% and 93% of your 

maximum heart rate. To figure out this range, follow the same formula used above, except change 

“64 and 76%” to “77 and 93%”. For example, for a 43-year-old person, the estimated maximum agerelated heart rate would be calculated as 220 – 43 years = 177 beats per minute (bpm). The 77% and 

97% levels would be:

• 77% level: 177 x 0.77 = 136 bpm, and

• 93% level: 177 x 0.97 = 172 bpm

This shows that vigorous-intensity physical activity for a 43-year-old person will require that the heart 

rate remain between 136 and 172 bpm during physical activity.

Recommendation #4: Consider methods to stay in communication during physical exercise such as

carrying a department radio or exercising in pairs when possible.

Discussion: In this incident, the FEO was on a training exercise by himself when he collapsed. 

Although emergency response measures were timely and appropriate, it may be advisable to be able to 

call immediately for assistance and/or to have another person on the scene to initiate resuscitative 

measures.

References

ADA [2019]. Diagnosing diabetes and learning about prediabetes. Arlington, VA: American Diabetes 

Association.

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

Diwakar A, Schmidt GA [2014]. Exercise-induced pulmonary hemorrhage in a nonathlete: case report 

and review of physiology. Lung 192(2):329–331.

Ghio AJ, Ghio C, Bassett M [2006]. Exercise-induced pulmonary hemorrhage after running a 

marathon. Lung 184(6):331–333.

Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, Braun LT, de Ferranti S, 

Faiella-Tommasino J, Forman DE, Goldberg R, Heidenreich PA, Hlatky MA, Jones DW, Lloyd-Jones 

D, Lopez-Pajares N, Ndumele CE, Orringer CE, Peralta CA, Saseen JJ, Smith SC Jr, Sperling L, 

Virani SS, Yeboah J [2019]. 2018 

AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the 

management of blood cholesterol: executive summary: a report of the American College of 
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Cardiology/American Heart Association Task Force on clinical practice guidelines. J Am Coll Cardiol 

73(24):3168–3209. 

Hinchcliff KW, Couetil LL, Knight PK, Morley PS, Robinson NE, Sweeney CR, van Erck E [2015]. 

Exercise induced pulmonary hemorrhage in horses: American College of Veterinary Internal Medicine 

consensus statement. J Vet Intern Med 29(3):743–758.

Hohmann E, Glatt V, Tetsworth K [2018]. Swimming induced pulmonary oedema in athletes - a 

systematic review and best evidence synthesis. BMC Sports Sci Med Rehabil 10:18.

Hopkins SR, Schoene RB, Henderson WR, Spragg RG, Martin TR, West JB [1997]. Intense exercise 

impairs the integrity of the pulmonary blood-gas barrier in elite athletes. Am J Respir Crit Care Med 

155(3):1090–1094.

IAFF [2022]. Exercise stress test. Washington, DC: International Association of Fire Fighters.

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

Washington, DC: International Association of Fire Fighters; Fairfax, VA: International Association of 

Fire Chiefs.

Kratz A, Ferraro M, Sluss PM, Lewandrowski KB [2004]. Case records of the Massachusetts General 

Hospital. Weekly clinicopathological exercises. Laboratory reference values. N Engl J Med 

351(15):1548–1563.

Marak CP, Joy PS, Gupta P, Bukovskaya Y, Guddati AK [2013]. Diffuse alveolar hemorrhage due to 

acute mitral valve regurgitation. Case Rep Pulmonol Epub 2013.

McKechnie JK, Leary WP, Noakes TD, Kallmeyer JC, MacSearraigh ET, Olivier LR [1979]. Acute 

pulmonary oedema in two athletes during a 90-km running race. S Afr Med J 56(7):261–265. 

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. 

Riebe D, Ehrman J, Liguori G, Magal M [2018]. General principles of exercise prescription. In: 

ACSM’s guidelines for exercise testing and prescription. 10th Ed. Philadelphia, PA: Wolters 

Kluwer/Lippincott Williams & Wilkins.

Saha BK, Chong WH [2021]. Diffuse alveolar hemorrhage in cardiac diseases. Lung 199(2):103–112.

Sakamoto A, Enomoto Y, Watabe H, Koyama Y, Matsumoto Y, Shimojo N, Marushima A, Kawano S, 

Inoue Y [2020]. Acute mitral valve regurgitation causing severe alveolar hemorrhage. Acute Med Surg

7(1):e504.

Spencer S, Dickinson J, Forbes L [2018]. Occurrence, risk factors, prognosis and prevention of 

swimming-induced pulmonary oedema: a systematic review. Sports Med Open 4(1):43.

Weather Underground [no date]. Historical weather. Weather Underground, The Weather Company.

Weiler-Ravell D, Shupak A, Goldenberg I, Halpern P, Shoshani O, Hirschhorn G, Margulis A [1995].

Pulmonary oedema and haemoptysis induced by strenuous swimming. BMJ 311(7001):361–362.
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West JB [2004]. Vulnerability of pulmonary capillaries during exercise. Exerc Sport Sci Rev 32(1):24–

30.

Whelton PK, Carey RM, Aronow WS, Casey Jr DE, Collins KJ, Himmelfarb CD, DePalma SM, 

Samuel Gidding, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith Jr SC, 

Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams Sr KA, Williamson JD, Wright Jr JT [2018]. 

2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the 

prevention, detection, evaluation, and management of high blood pressure in adults: a report of the 

American College of Cardiology/American Heart Association Task Force on Clinical Practice 

Guidelines. J Am Coll Cardiol 71(19):e127–e248. 

Investigator Information

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

Program, Cardiac/Medical Team, in Cincinnati, Ohio. TJ Welch is a Firefighter Safety Specialist and 

worked in volunteer, industrial and municipal fire departments and co-authored the report. Mr. Welch 

is a State Certified Fire Officer, founding member of the California Incident Command Certification 

System, and chaired the CICCS committee on Physical Fitness Standards. Dr. Robert Harrison MD, 

MPH (California Department of Public Health) provided medical consultation, and Laura Styles, MPH 

(Public Health Institute) also contributed to this report.

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.
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Appendix A

Exercise Stress Testing

The term exercise stress test refers to stressing the body by putting an exercise load on it and 

measuring the response. Exercise stress tests can be done in several ways; however, most people relate 

the term to just cardiovascular testing. Exercise stress testing is an important tool used by physicians 

and exercise specialists to:

• Determine whether an individual is physically fit to perform essential job duties without undue 

risk of harm to self or others.

• Monitor the effects of exposure to specific biological, physical, or chemical agents that may be 

related to hazardous working conditions.

• Detect any patterns of disease in the workforce that might indicate underlying work- related 

problems.

• Provide the fire fighter with information about his/her current health.

• Provide a cost-effective investment in the early detection, disease prevention, and health 

promotion of the fire fighter.

• Develop recommendations for exercise prescription and rehabilitation.

• Comply with federal, state, provincial, and local requirements.

An exercise stress test is just one diagnostic test that a physician may use in a fitness for duty 

determination. The determination of fitness for duty must not be made based on a single test, but rather 

on a comprehensive evaluation of the individual that includes diagnostic testing, personal medical 

history, and other indicators of health status.

There are two levels of evaluating aerobic exercise capacity, either maximal or sub-maximal.

Maximal aerobic exercise testing makes the fire fighter work until exhaustion to directly determine 

VO2 max and maximum heart rate. These tests must only be performed by qualified medical personnel 

under the supervision of the fire department physician and must be conducted in a medical care setting.

Sub-maximal exercise stress testing makes the fire fighter work until a pre-determined heart rate is 

achieved. The pre-determined heart rate is typically 85 percent of the predicted maximum heart rate. 

Such testing only allows for a prediction of maximum exercise capacity. The IAFF/IAFC Fire Service 

Joint Labor/Management Wellness-Fitness Initiative recommends a sub-maximal exercise stress test 

without EKG because of the safety of the test, they are relatively inexpensive, are easier to administer 

by an exercise specialist, and they provide the sufficient information needed for the evaluation of 

cardiopulmonary fitness [IAFF/IAFC 2018]. (Note: The IAFF/IAFC Fire Service Joint 
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Labor/Management Wellness-Fitness Initiative also recommends a resting EKG as part of an 

emergency responders’ annual medical evaluation.)

Exercise stress test can be administered in conjunction with many different physiologic monitoring 

devices. Monitoring devices will be selected based upon the goal of the test and the depth of data 

necessary to achieve the goals.

Exercise Stress Testing with heart rate monitoring measures the heart’s performance and determines 

exercise capacity (VO2 max). This information is used to determine safe levels of exercise. Such 

testing may be either maximal or sub-maximal. Maximal capacity testing must only be performed by 

qualified medical personnel under the supervision of the fire department physician and must be 

conducted in a medical care setting.

Exercise Stress Tests with EKG allow the physician and exercise specialist to determine maximal 

exercise capacity (VO2 max) and detect early signs of coronary artery disease. An EKG 

(electrocardiogram, also called ECG) is a non-invasive test that records the heart’s electrical impulses. 

It can identify abnormalities in heart rate and rhythm, and it can help to establish whether the heart 

muscle is receiving enough oxygen. Some early signs of angina or myocardial infarctions can be seen 

on a 12-lead EKG. Such testing can be either a sub-maximal or maximal test. Maximal capacity testing 

must only be performed by qualified medical personnel under the supervision of the fire department 

physician and must be conducted in a medical care setting.

Exercise Stress Test with EKG and direct respiratory gas analysis allows the physician and 

exercise specialist to determine exercise capacity (VO2 max), determine safe levels of exercise, detect 

early signs of coronary artery disease and to determine maximal oxygen consumption, respiratory gas 

exchange ratio, and ventilatory equivalent for oxygen. Such testing will require the individual to breath 

into a tube during the test. Such testing can be either a sub-maximal or maximal test. Maximal capacity 

testing must only be performed by qualified medical personnel under the supervision of the fire 

department physician and must be conducted in a medical care setting.

References

IAFF [2022]. Exercise stress test. Washington, DC: International Association of Fire Fighters.

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

Washington, DC: International Association of Fire Fighters; Fairfax, VA: International Association of 

Fire Chiefs.