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Executive Summary

On October 23, 2017, at 1900 hours a 31-year-old male volunteer fire fighter (FF) began a regularly 

scheduled weekly training session. The training was held at the county fire training center and was 

focused on automobile extrication. Minutes after the hands-on training began, the FF began having a 

seizure. An ambulance was dispatched at 2021 hours and arrived on scene at 2035 hours. The FF was 

loaded into the ambulance and en route to the hospital emergency department (ED) he suffered a 

cardiac arrest. Advanced cardiac life support (ACLS) was initiated in the ambulance and continued in 

the hospital ED. Efforts to revive the FF were unsuccessful and the FF was pronounced dead at 

2256 hours. 

The death certificate listed the cause of death as “cardiac arrest.” No autopsy was performed. The FF’s

past medical history was significant for epilepsy and smoking. NIOSH investigators concluded the 

seizure suffered by the FF may have played a role in precipitating his sudden cardiac event. 

Key Recommendations 

NIOSH offers the following recommendations to reduce the risk of sudden cardiovascular events and 

other incapacitating conditions among fire fighters at this and other fire departments across the 

country. 

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

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

Program for Fire Departments.

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

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

various components of NFPA 1582. 

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

In addition, NIOSH offers the following recommendation: 

• Perform autopsies on all on-duty fire fighter fatalities. 
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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 claimor 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).
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Introduction 

On October 23, 2017, at 1900 hours a 31-year-old male volunteer FF reported for weekly training. 

After traveling to the county fire training center and receiving a classroom briefing, the FF and other 

department members retrieved tools from the apparatus and began training. Within two minutes of 

beginning the training, the FF had a seizure. While being transported to the hospital, the FF suffered a 

cardiac arrest. Attempts to revive him were unsuccessful. The U.S. Fire Administration notified 

NIOSH of this fatality on October 25, 2017. NIOSH contacted the affected FD on October 27, 2017, 

and again on March 31, 2018, to gather additional information and to initiate the investigation. On 

April 9, 2018, a contractor for the NIOSH Fire Fighter Fatality Investigation and Prevention Program 

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

 

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

 Fire Chief (who was Assistant Chief at the time of the incident)

 Captain (who was Fire Chief at the time of the incident)

 Father of the FF

The NIOSH investigator reviewed the following documents: 

 FD incident report 

 County training academy incident report 

 Fire Marshall report

 Emergency medical service (ambulance) report

 Emergency medical service (EMS) report for ALS unit that intercepted the basic life support 

(BLS) unit 

 Hospital ED records

 Primary care physician records

 Death certificate

Investigation 

On October 23, 2017, at 1900 hours a 31-year-old male volunteer FF reported to his fire station for 

weekly training. The FF and other department members then traveled approximately 20 miles to the 

county training academy for hands-on automobile extrication training. The training was the second day 
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of a two-part series on automobile extrication. The first session had been classroom training and this 

night was scheduled to be hands-on training, where personnel practiced using tools and following 

procedures and then performed a simulated drill. The FF and department members arrived at the 

training academy at 1930 hours and reported to the classroom, where they signed in, reviewed the 

scenario, and developed a plan for the evening drill. The group then went to the fireground where there 

were two cars positioned for an automobile extrication drill. It was a humid evening, with an ambient 

temperature of 68°F, relative humidity of 83%, and a wind speed of 8 miles per hour [Weather 

Channel no date]. The chief of the department and instructors discussed the tools that would be used 

and then the FF and other department members removed extrication tools from the apparatus (an 

engine and utility truck) and placed them in proximity to the automobiles. 

After preparations were completed, at approximately 2020 hours, the FF was working with the Chief, 

who was serving as incident command. As the FF began the drill, the FF stepped back from the car and 

started shaking. The Chief recognized that the FF was beginning to have a seizure, put his arm on the 

FF’s shoulder, and spoke to the FF. He then reached around the FF and helped him to the ground. As 

the Chief attended to the FF, an instructor called for an ambulance. As the seizure continued, the Chief 

noticed a small amount of blood from the right side of the mouth. Oxygen was provided by mask until 

the ambulance arrived.

The ambulance was dispatched at 2021 hours and arrived on scene at 2028 hours. The FF was placed 

on a stretcher and loaded into the ambulance. Oxygen was administered via mask. Attempts to obtain 

vital signs were unsuccessful due to seizure activity. At 2035 hours, the ambulance was intercepted by 

an ALS unit and paramedics took over care. Paramedics found the FF unconscious, unresponsive, and 

actively seizing in a full-body tonic-clonic seizure. At approximately 2041 hours, paramedics 

administered Ativan® (lorazepam) (2 milligrams) and seizure activity decreased but the FF continued 

to have difficulty breathing. Medical command gave orders for another dose of Ativan, and at 

approximately 2044 hours, a third dose of Ativan was administered. Approximately two minutes later, 

around 2046 hours, the FF went into cardiac arrest and cardiopulmonary resuscitation (CPR) was 

initiated. The cardiac monitor indicated that the FF was in asystole. The FF remained unresponsive but 

his heart rhythm did briefly return to a sinus rhythm before returning to asystole. The FF was 

successfully intubated on the second attempt with placement of the endotracheal tube (ETT) verified 

by auscultation, misting in the tube, direct visualization, and end-tidal CO2. Intravenous (IV) access 

was gained in the left antecubital vein and four rounds of epinephrine were administered en route to 

the hospital. The ambulance arrived at the hospital at 2058 hours and patient care was transferred to 

ED staff.

In the ED, the rhythm remained asystole. The FF was placed on a ventilator. The initial bedside 

echocardiogram revealed minimal ventricular wall motion. At 2107 hours, CPR was paused which 

showed the absence of a femoral pulse. CPR was resumed. Cardiac medications were administered, 

including epinephrine and amiodarone. At 2111 hours, a second ultrasound revealed no cardiac wall 

motion. At 2113 hours, CPR was paused and the FF had a return of circulation (carotid and femoral 

pulses). At 2122 hours, the FF’s rhythm reverted to asystole. CPR was again initiated. A central line 
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was obtained to administer medications. At 2128 hours, the FF regained a pulse. Additional cardiac 

medications were given. At 2132 hours, the FF’s heart rate began to decrease and CPR was again 

initiated. At 2133 hours, the FF again became asystolic. Additional cardiac medications were given

and a cardiac pacer was set. At 2148 hours, a bedside ultrasound was positive for cardiac activity but 

blood pressure was only 51/20 millimeters of mercury (mmHg). One minute later, the blood pressure 

was 105/37 mmHg. 

Around 2150 hours, a decision was made to transfer the FF to a more advanced medical center. 

However, before he could be transferred his condition deteriorated. At 2243 hours, his heart rate was 

60 beats per minute and his blood pressure was 76/38 mmHg. At 2248 hours, the pacer was shut off 

and the rhythm was asystole. CPR was again initiated and cardiac medications were administered. At 

2256 hours, more than two hours after his initial cardiac arrest, it was determined that resuscitation 

efforts were futile, and the FF was pronounced dead. 

During the ED treatment, multiple tests were performed, including a CT of the spine which showed no 

evidence of acute fracture or dislocation; a CT of the brain which showed only a small amount of fluid 

in the sinuses; a CT of the chest which showed no enlargement of the heart, no thoracic aneurysm or 

dissection, and mild respiratory changes; and a CT of the abdomen and pelvis which showed mild 

vascular calcification but no traumatic injuries. The FF’s prior pertinent medical records were 

reviewed. The FF was last seen in the ED for abdominal pain in December of 2013. 

Medical Findings

The death certificate listed the cause of death as cardiac arrest. Because the FF had a witnessed cardiac 

arrest, and the cause of death was known, an autopsy was not performed. 

The FF was diagnosed with epilepsy at 16 years of age. He was diagnosed with localization-related 

(focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not 

intractable, without status epilepticus, and took anti-seizure medication and worked with his primary 

care physician to find the proper dosage to limit his seizures and control tremors. The FF was currently 

taking Lamictal® and Depakote® and his family reported good compliance with medications. The FF

had no other known medical conditions. The FF saw his physician in June 2017 and reported that his 

last seizure was approximately 6 weeks prior. At this time, the physician began working with the FF to 

change his medication and gave him a note saying that he could not participate as a fire fighter for 

90 days. The FF complied with the 90-day period and then returned to participation with the FD. The 

FF returned to the physician’s office one week later for a follow-up. At this visit, the FF had a blood 

pressure of 120/80 mmHg (normal resting systolic is 90–119 mmHg and normal resting diastolic is 

60–79 mmHg). The FF had no other significant medical issues. The FF did not regularly engage in 

physical activity. He was a smoker and was 72 inches tall and weighed 198 pounds, giving him a body 

mass index (BMI) of 26.9 kilograms per meter squared (BMI > 25 is considered overweight) [NHLBI 

no date]. 
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Fire Department

At the time of the NIOSH investigation, the FD consisted of approximately 45 uniformed personnel 

operating out of a single fire station. It served a population of approximately 10,000 in a geographic 

area of just over two square miles. 

Employment and Training

Applicants must be at least 18 years of age, complete an application, and pass a background check to 

join the FD. Once applicants pass the background check, they are voted on by the town council. 

Preplacement/Periodic/Return to Work Medical Evaluations 

The FD requires preplacement medical evaluations for applicants. Medical evaluations are completed 

by the applicant’s primary care physician who must provide a written note certifying that the applicant 

is in good health. The FD does not require medical evaluations for members. The FD does provide 

annual testing (“fit testing”) for self-contained breathing apparatus (SCBA) use. Members are required 

to provide medical clearance from their own physician following a serious injury or illness. The FF 

joined the FD in 2006. He was not cleared for SCBA use, interior fire fighting, use of ladders, or 

driving due to his epilepsy. 

Wellness/Fitness Programs

The FD does not offer a comprehensive wellness/fitness program. 

Discussion 

Sudden Cardiac Events

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

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

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

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

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

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

was a smoker. 

The Pathophysiology of Sudden Cardiac Arrest/Death

Sudden cardiac death may be caused by a heart attack (myocardial infarction) or a fatal arrhythmia 

(disruption in the electrical signal of the heart) that causes the heart to stop beating (cardiac arrest). 

The FF was being treated by EMS personnel when he experienced a sudden cardiac arrest. 

Sudden cardiac arrest/death can also result from non-cardiac causes, particularly in younger persons 

(e.g., < 35 years old). Some of the more common non-cardiac causes include pulmonary embolism, 

asthma, severe infection, cerebral hemorrhage, and epilepsy [Puranik et al. 2005; Vaartjes 2009]. 
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Epilepsy

Epilepsy is a neurological disease that causes recurrent seizures due to abnormal electrical activity in 

the brain. Epilepsy is usually diagnosed when a person has had two or more seizures that were 

unprovoked (not secondary to fever, concussion, electrolyte imbalance, alcohol withdrawal, etc.) 

[Fisher et al. 2014]. It is not understood why the brains of persons with epilepsy are more susceptible 

to seizures. 

Epilepsy and Sudden Death

Individuals with epilepsy are at increased risk of sudden cardiac arrest and have a significantly worse 

survival rate than the general population [Bardai et al. 2012; Stecker et al. 2013]. It is not known why 

individuals with epilepsy are at increased risk of cardiac arrest, but there is evidence that epilepsy may 

lead to changes in cardiac electrophysiology, including QTc prolongation and early repolarization 

pattern [Bardai et al. 2015; Lamberts et al. 2015]. 

Sudden unexpected death in epilepsy (SUDEP) describes death in a patient with epilepsy that occurs 

after a seizure in most cases, usually a generalized tonic-clonic seizure (grand mal seizure) [Devinsky 

2011]. Documenting the incidence of SUDEP is difficult because there are varying definitions, it does 

not have a code in the current International Classification of Diseases (ICD) list, and it is often under

recognized by medical examiners, coroners, and clinicians who complete death certificates [Ryvlin and 

Cascino 2017; Tomson et al. 2008]. A systematic review of studies investigating the incidence of 

SUDEP in the general population found that the cumulative risk of SUDEP was related to the age of 

the individual and the age at the onset of epilepsy [Thurman et al. 2014]. Based on this analysis, an 

individual who is 30 years of age and was diagnosed at 15 years of age has approximately a 3% 

cumulative risk of SUDEP. The underlying mechanism of death in SUDEP is difficult to determine

and may be multifactorial; possible explanations involve seizure-induced cardiac, respiratory, or 

neurologic (“cerebral shutdown”) causes [Devinsky 2011; Tolstykh and Cavazos 2013]. In this case, 

the FF had a witnessed cardiac arrest while he was being treated by EMS. To reduce the risk of 

SUDEP the current recommendations are to focus on prevention through control of seizures, including 

medication and counseling on lifestyle [Devinsky 2011]. 

Occupational Medical Standards for Structural Fire Fighters

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

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

in individuals with underlying cardiovascular disease [Smith et al. 2016]. Research relying on autopsy 

data suggests that the majority of fire fighter duty-related sudden cardiac deaths have coronary 

atherosclerosis, cardiomegaly/left ventricular hypertrophy, or both conditions [Geibe et al. 2008; Kales 

et al. 2003; Yang et al. 2013]. To reduce the risk of sudden cardiac events or other incapacitating 

conditions among fire fighters, the NFPA developed 1582, Standard on Comprehensive Occupational 

Medical Program for Fire Departments [NFPA 2018]. 

NFPA 1582 addresses epilepsy in Chapter 6.17 (Neurological Disorders) for candidates and Chapter 

9.13.6 (Single Unprovoked Seizure and Epileptic Conditions) for fire fighters [NFPA 2018]. 
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According to this guidance, candidates with epilepsy would not meet medical requirements to enter 

fire fighting training (Category A medical condition) unless a list of specific criteria is met, to include 

no seizures in the past 10 years [NFPA 2018]. For fire fighters, epilepsy would compromise the ability 

to safely perform a number of job tasks, such as wearing SCBA, operating from heights, critical 

problem-solving in hazardous environments, operating fire apparatus or other emergency vehicles, etc. 

[NFPA 2018]. NFPA 1582 advises the physician to report applicable limitations to the fire department 

unless the fire fighter meets a number of certain criteria, which includes no seizures for the past 

10 years [NFPA 2018]. 

The FD did not require medical evaluations for members. However, the FD was aware that the FF had 

a seizure disorder and the FF was not cleared to perform several essential job tasks, including wearing 

SCBA, entering a burning building, operating on a ladder or roof, or driving an apparatus. 

NIOSH offers the following recommendations to reduce the risk of heart attacks, sudden cardiac arrest, 

and other incapacitating conditions among fire fighters at this and other fire departments across the 

country. 

Recommendations 

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

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

Departments.

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

in NFPA 1582 [NFPA 2018]. These evaluations are performed to determine a fire fighter’s medical 

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

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

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

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

the various components of NFPA 1582. 

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

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

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

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

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

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

wear during various types of emergency operations. 

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

fire fighters.

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

cardiovascular disease and improve cardiovascular capacity is found in NFPA 1583, Standard on 
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Health-Related Fitness Programs for Fire Fighters [NFPA 2015], the IAFF/IAFC Fire Service Joint 

Labor Management Wellness/Fitness Initiative (WFI) [IAFF and IAFC 2018], the U.S. Fire 

Administration Health and Wellness Guide for the Volunteer Fire and Emergency Services [USFA 

2009], and in 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 work days [Aldana 2001; Stein 

et al. 2001]. Health promotion programs for fire fighters have been shown to reduce coronary heart 

disease risk factors and improve fitness levels, with mandatory programs showing the most benefit 

[Blevins et al. 2006; Dempsey et al. 2002; Womack et al. 2005]. 

Given the FD’s structure and budget limitations, helpful resources for starting a program include the 

Heart-Healthy Firefighter Program developed by the National Volunteer Fire Council [NVFC, no 

date] and the Health and Wellness Guide for the Volunteer Fire and Emergency Services [USFA 

2009]. 

In addition, NIOSH offers the following recommendation: 

Recommendation #4: Perform autopsies on all on-duty fire fighter fatalities. 

Discussion: The U.S. Fire Administration recommends that an autopsy is obtained for each fire fighter 

fatality that occurs while on duty. Obtaining this information can serve the following purposes, as 

outlined in the Firefighter Autopsy Protocol [USFA 2008]: 

1. To better understand the causes of fire fighter deaths so that these findings can contribute to 

improved fire fighter health and safety equipment, procedures, and standards 

2. To help determine survivors’ eligibility for death benefits through the federal government’s 

Public Safety Officer Benefits Program, as well as state and local programs 

3. To address increased attention to the study of deaths among active/retired fire fighters that 

could be occupationally related.

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

http://dx.doi.org/10.1016/j.amjcard.2013.08.029. 

Investigator Information

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

Program, Cardiac/Medical Line-of-Duty Death (LODD) Component, within the Division of 

Surveillance, Hazard Evaluations, and Field Studies, located in Cincinnati, Ohio. Denise L. Smith, 

PhD, led the investigation and authored the report. Dr. Smith is Tisch Distinguished Professor of 

Health and Exercise Sciences and Director of the First Responder Health and Safety Laboratory at 

Skidmore College in Saratoga Springs, New York. She is also a member of the NFPA Technical 

Committee on Fire Service Occupational Safety and Health. Dr. Smith was working as a contractor for

NIOSH during this investigation. Wendi Dick, MD, MSPH, provided medical consultation and 

contributed to the report. Dr. Dick is Medical Officer for the Cardiac/Medical LODD Component at 

NIOSH. 

Additional Information

NIOSH has investigated other medical LODDs in fire fighters with seizure disorder. Below are links to 

these reports. 

F2007-05

Sep 21, 2006: 38-year-old volunteer fire fighter/emergency medical technician (FF/EMT) suffers 

sudden death 2 hours after completing vehicle extrication training - New York. PDF 

F2007-04 

Dec 07, 2006: 25-year-old fire fighter dies during the night after responding to a structure fire - 

Pennsylvania. PDF 

F2006-18 

Mar 31, 2006: 34-year-old FF/EMT suffers sudden death while on-duty - South Carolina. PDF 

F2002-27 

May 16, 2001: 30-year-old fire fighter dies during the night at fire station - Missouri. PDF 

The reports can also be accessed via https://www.cdc.gov/niosh/fire/investigations/investigations.html. 
Page 11 

Report # F2018-04

31-Year-Old Fire Fighter Suffers a Seizure at Fire Department 

Training and Dies of Sudden Cardiac Arrest—New Jersey 

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.