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Executive Summary

On January 10, 2016, a 56-year-old male career firefighter/paramedic (FF/P) worked a 24-hour shift. 

He responded to several calls including a vehicle fire, medical call, and activated alarm. The following 

day, he worked with the Fire Prevention bureau for over 6 hours. In the evening, the FF/P shoveled 

snow at his home and then went to his bedroom. His family found him unresponsive in his bed 

10–15 minutes later. They started cardiopulmonary resuscitation (CPR). Emergency medical services 

(EMS) found the FF/P unresponsive, pulseless, and not breathing. He was in asystole (no heart 

rhythm). On scene and enroute to the emergency department (ED), EMS provided CPR and advanced 

cardiac life support measures. ED staff treated the FF/D without success for 35 minutes and 

pronounced him dead at 2147 hours. 

The autopsy report listed hypertensive-arteriosclerotic cardiovascular disease as the immediate cause 

of death. The report listed diabetes mellitus and obesity as contributing conditions. Autopsy findings 

included cardiomegaly, biventricular myocardial thickening, and left ventricular dilation. Two main 

arteries had calcified atherosclerotic plaque. The left anterior descending artery had significant 

stenosis. National Institute for Occupational Safety and Health (NIOSH) investigators concluded that 

the physical stress of shoveling snow likely triggered the sudden cardiac event. Given his uncontrolled 

diabetes mellitus and other cardiovascular disease risk factors, a more careful evaluation for fitness for 

firefighting duty, including a full medical evaluation consistent with National Fire Protection 

Association (NFPA) 1582 was needed. 

Key Recommendations

• Ensure that all firefighters receive an annual medical evaluation consistent with NFPA 1582, 

Standard on Comprehensive Occupational Medical Program for Fire Departments. 

• Incorporate exercise stress tests (ESTs) into the fire department medical evaluation program 

for firefighters at increased risk for coronary heart disease. 

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

• Perform an annual physical performance (physical ability) evaluation. 
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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 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).
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Introduction

On January 11, 2016, a 56-year-old firefighter/paramedic (FF/P) suffered a cardiac arrest at his home 

after shoveling snow. He had been on duty earlier that day in the Fire Prevention office and prior to 

that he had been on duty for a 24-hour shift. The U.S. Fire Administration notified the National 

Institute for Occupational Safety and Health (NIOSH) of this fatality on January 12, 2016. NIOSH 

contacted the affected fire department (FD) on January 15, 2016 and again on June 20, 2016, to gather 

additional information and to initiate the investigation. On August 1, 2016, a contractor for the NIOSH

Fire Fighter Fatality Prevention and Investigation Program (the NIOSH investigator) conducted an 

on-site investigation of the incident.

During the investigation, NIOSH personnel interviewed the following people: 

• Fire Chief

• Deputy Chief 

• Union President

• Firefighter/paramedic serving with the FF/P

• FF/P’s wife

NIOSH personnel reviewed the following documents: 

• FD standard operating guidelines 

• FD incident report 

• FD injury/illness investigation report 

• FD medical evaluation records 

• Emergency medical service (ambulance) report

• Hospital emergency department (ED) records

• Death certificate

• Autopsy report 

Investigation

On January 10, 2016, a 56-year-old male career FF/P reported for a 24-hour shift and was assigned to 

drive an Engine. The FF/P performed the daily check of the engine and his self-contained breathing 
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apparatus and participated in typical house cleaning and chores. At 1304 hours the FF/P, the lieutenant 

(LT), and another FF were dispatched to an activated residential fire alarm. The call was cancelled 

enroute. At 1708 hours the engine crew responded to a vehicle fire. The FF/P helped advance a 

13⁄4-inch hoseline to extinguish the fire, overhaul the vehicle, and reload the hose. The crew cleared the 

scene at 1738 hours. 

At 1801 hours the engine crew responded to an ambulance assistance call in an apartment building 

with a patient on the 4th floor. The FF/P assisted with retrieving and carrying medical equipment up the 

stairs. As they ascended the stairs, the LT noticed that the FF/P was short of breath, so the two of them 

stayed on the 3rd floor waiting for information/requests from the ambulance crew while the second FF 

went to the 4th floor and assisted the ambulance crew. When questioned about how he was doing, the 

FF/P responded that he was fine and that he just needed a minute to catch his breath. The LT attributed 

the response to the extremely cold weather (8°F, winds out of the west at 12.7 miles per hour (mph), 

wind chill of -8°F) [Weather Channel 2016]. A short time later the FF/P carried medical equipment 

back to the engine and assisted the ambulance crew with patient care. The call was terminated at 

1818 hours. Back at the fire station after the call, the other FF noticed that the FF/P seemed out of 

breath and asked him if he was okay. The FF/P responded that he was fine. The LT spoke with the 

FF/P at around 2315 hours. Again, the FF/P reported that he was fine.

At 0615 hours the engine crew responded to an activated fire alarm. The FF/P stayed with the engine 

while the LT investigated the alarm. At 0637 hours they were cleared from the call. At 0730 hours, the 

FF/P was relieved of duty. He reported to the Fire Prevention office where he worked on a plan review 

and other fire prevention activities until 1345 hours.

The FF/P arrived home after 1500 hours and spent the afternoon doing activities around the house 

including working on the computer, fixing a cord for an electronic devise, etc. He had dinner with his 

family and in the evening, he went outside and cleared snow (< 1 inch) from the front walkway. The 

family noticed nothing out of the ordinary. At approximately 2050 hours he entered his house and went 

to his bedroom. Approximately 10 minutes later his wife found him on his back on the bed in an 

unresponsive state. Family called 911 and initiated cardiopulmonary resuscitation (CPR). The 

ambulance was dispatched at 2105 hours and arrived on-scene at 2109 hours. Emergency medical 

services (EMS) personnel found the FF/P unresponsive, pulseless, and not breathing. His pupils were 

fixed and dilated. EMS took over CPR, obtained an airway (King airway), and provided oxygen via 

bag-valve mask. The cardiac monitor revealed asystole. Paramedics inserted an intraosseous line and 

provided cardiac medications. The ambulance departed the scene at 2120 hours and arrived at the 

emergency department (ED) at 2124 hours. 

In the ED the FF/P remained in asystole. An endotracheal tube was inserted. An ultrasound confirmed 

no heart activity. At 2142 hours, the FF/P was pronounced dead. 

Medical Findings

The County Medical Examiner office completed the death certificate. It listed hypertensive 
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arteriosclerotic cardiovascular disease as the immediate cause of death, and diabetes mellitus and 

obesity as significant conditions contributing to death but not resulting in the underlying cause. The 

autopsy revealed cardiomegaly (683 grams), biventricular myocardial hypertrophy (left ventricular 

thickness of 1.5 centimeter [cm]), left ventricular dilation, and coronary artery atherosclerosis, 

including calcified plaque in the right coronary artery and the left anterior descending artery. The left 

anterior descending artery had luminal narrowing of 80% due to plaque. See Appendix A for a more 

detailed description of autopsy findings. 

The FF/P had a history of diabetes mellitus and high cholesterol. At his last FD medical evaluation in 

February 2015, he completed an Occupational Safety and Health Administration (OSHA) Respiratory 

Medical Evaluation Questionnaire and indicated that he was a smoker and had diabetes. The FF/P 

reported that he was taking oral medication to control his diabetes. The record also notes that the FF/P 

had taken Lipitor, a cholesterol lowering drug. He also stated that he had no cardiovascular or heart 

symptoms and denied having shortness of breath or chest pain with exertion. His blood pressure was 

133/91 millimeters of mercury (mmHg) (normal resting systolic is 90–119 mmHg and normal resting 

diastolic is 60–79 mmHg). A pulmonary function test (spirometry) indicated moderate obstructive 

disease. The FF/P was 77 inches tall and weighed 330 pounds, giving him a body mass index of 

39.1 kilograms per meter squared [CDC 2015]. No blood work was performed. The occupational 

medicine physician noted that the FF/P had non-insulin diabetes mellitus (with last known hemoglobin 

A1C of 7.7% (normal is < 5.7%), that the FF/P reported having a stress test 5 years ago, and that he 

was a current smoker with evidence of moderate obstructive disease. Based on these observations, the 

physician encouraged the FF/P to follow up with his primary care physician (PCP) regarding smoking 

cessation, diabetes control, and abnormal spirometry. On the basis of his risk factors for heart disease, 

the physician further advised the FF/P that his PCP may wish to conduct an EST. We requested but did 

not receive medical records from the FF/P’s PCP. The FF/P was cleared for full firefighting duty. 

Fire Department

At the time of the NIOSH investigation, the FD consisted of 63 uniformed personnel working out of 

three fire stations. It served a population of approximately 52,000 in a geographic area of 4.5 square 

miles. In 2015, the FD responded to approximately 6800 calls. 

Employment and Training

Applicants must be between 21–35 years of age; have a high school diploma or a general education 

development (GED) diploma; have a valid state driver’s license; and possess a paramedic license. 

Applicants take a written exam and top scorers are invited to an oral examination. Once a conditional 

offer to hire is made, the candidate must pass a background check, a psychological evaluation, and a 

medical evaluation. A new member must complete training to the Operation Level (state equivalent of 

Firefighter I and II). New members spend 2 weeks on day shifts to be oriented to the policies and 

procedures of the FD before being placed on a 24-hour shift (24 hours on duty, 48 hours off duty). The 

new member is on probation for 1 year. The FF/P was certified as a Firefighter III and driver/operator 

and was a licensed paramedic. He had been with the FD for 28 years. 
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Preplacement Medical Evaluation

The FD requires preplacement medical evaluations for all applicants. Evaluations are conducted by a 

contract occupational medical group for the FD. Components of this evaluation include the following: 

• Complete medical history

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

• Complete blood count 

• Urinalysis

• Urine drug screen 

• Audiogram 

• Vision test

• Respirator use questionnaire

• Spirometry

• Resting electrocardiogram (EKG) 

• Chest X-ray

Periodic medical evaluations provided annually to all members includes: 

• Medical history

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

• Audiogram 

• Vision test

• Respirator use questionnaire

• Spirometry

Once the medical evaluation is complete, the contracted health care provider makes a determination 

regarding medical clearance for firefighting duties and forwards this decision to the FD office. The 

FF/P had yearly medical evaluations. 

Wellness/Fitness Programs

The FD does not have a comprehensive wellness/fitness program as recommended by the International 

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

Wellness Fitness Initiative [IAFF, IAFC 2008]. The FD has exercise equipment available for its 

members and FF are permitted to exercise on duty. Nonetheless, NIOSH recommends a mandatory 
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wellness/fitness program to ensure all members receive the benefits of a wellness/fitness program. 

Fellow firefighters report that the FF did not engage in fitness activities at the fire station.

Discussion 

Sudden Cardiac Events 

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

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

are grouped into non-modifiable and modifiable. Non-modifiable risk factors include age older than 

45, male gender, and family history of coronary artery disease. Modifiable risk factors include diabetes 

mellitus, smoking, high blood pressure, high blood cholesterol, and obesity/physical inactivity [AHA 

2016; NHLBI 2016]. The FF/P had four of the modifiable risk factors. 

The narrowing of the coronary arteries by atherosclerotic plaques occurs over many years, typically 

decades [Libby 2013]. However, the growth of these plaques probably occurs in a nonlinear, often 

abrupt fashion. Heart attacks (myocardial infarctions) typically occur with the sudden development of 

complete blockage (occlusion) in one or more coronary arteries that have not developed a collateral 

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

atherosclerotic plaques [Libby 2013]. Heart attacks and sudden cardiac death can be triggered by heavy 

physical exertion [Albert et al. 2000; Mittleman et al. 1993; Willich et al. 1993], including snow 

shoveling [Franklin et al. 2001] and firefighting activity [Kales et al. 2003, 2007; NIOSH 2007]. 

Establishing the occurrence of an acute heart attack requires any of the following: characteristic EKG 

changes, elevated cardiac enzymes, or coronary artery thrombus/plaque rupture. In this case, the FF/P 

did not have an EKG because he never regained a heart rhythm, cardiac enzyme testing was not 

performed (but we would not expect the enzymes to become positive for at least 4 hours post-heart 

attack), and no coronary artery blood clot/plaque rupture was found at autopsy. Occasionally (16%–

27% of the time) post-mortem examinations do not reveal the coronary artery blood clots/plaque 

rupture during acute heart attacks [Davies 1992; Farb et al. 1995]. The clinical scenario of this FF/P’s 

death is consistent with a heart attack or a primary cardiac arrhythmia [Libby 2005; Thaulow et al.

1993]. Hypertension, left ventricular hypertrophy, cardiomegaly, coronary heart disease, smoking, and 

diabetes all increase the risk of an arrhythmia causing sudden cardiac death [AHA 2014; Haider et al.

1998; Mayo Clinic 2016; Verdecchia et al. 1998]. 

Cardiomegaly/Left Ventricular Hypertrophy

On autopsy, the FF/P had an enlarged heart (cardiomegaly), left ventricular dilation, and thickening 

(hypertrophy) of the heart wall. Cardiac dilation is an increased volume of any cardiac chamber or 

combination of chambers, usually leading to an increased size of the heart. Causes are varied but 

cardiac dilation is typically caused by cardiomegaly or myocardial hypertrophy [Siegel 1997a]. 

Hypertrophy of the heart’s left ventricle (LVH) is a common finding among individuals with longstanding high blood pressure (hypertension), a heart valve problem, or cardiac ischemia (reduced 

blood supply to the heart muscle) [Siegel 1997b; Tavora et al. 2012]. LVH and cardiomegaly are 

both structural heart changes that increase the risk for arrhythmias and sudden cardiac death [Tavora 

et al. 2012]. 
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Diabetes Mellitus

The voluntary National Fire Protection Association standard NFPA 1582, Standard on Comprehensive 

Occupational Medical Program for Fire Departments, provides guidance for fire department 

physicians when treating firefighters with diabetes [NFPA 2013a]. The standard states that firefighters 

with diabetes mellitus that is controlled by diet, exercise, or oral hypoglycemic agents should be 

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

• has had hemoglobin A1C measured at least 4 times a year over the last 12 months prior to 

evaluation if the diagnosis of diabetes has been present over 1 year 

• if on oral hypoglycemic agents, has had no episodes of severe hypoglycemia (defined as 

requiring assistance of another in the preceding year)

• has achieved a stable blood glucose as evidenced by hemoglobin A1C level less than 8% 

during the prior 3-month period

• has a dilated retinal exam by a qualified ophthalmologist or optometrist that shows no higher 

grade of diabetic retinopathy than microaneurysms

• has normal renal function on the basis of a calculated creatinine clearance greater than 

60 milliliters per minute and absence of proteinuria

• has no autonomic or peripheral neuropathy

• has normal cardiac function without evidence of myocardial ischemia on cardiac stress testing 

(to at least 12 METs) by EKG and cardiac imaging.

The FF/P had uncontrolled diabetes; he reported his hemoglobin A1C to be 7.7% in 2015. Although 

the occupational physician requested that the FF/P follow-up with his PCP, documentation of 

controlled blood glucose levels was not evident in the annual medical exam records. NFPA 1582 

guidance recommends such documentation.

Occupational Medical Standards for Structural Firefighters

NFPA 1582 provides guidance on the components of a preplacement and annual medical evaluation 

and medical fitness for duty criteria [NFPA 2013a]. The FF/P had yearly FD medical evaluations, but 

the medical evaluation did not require all the components of the NFPA 1582 Standard. Despite his 

history of uncontrolled diabetes mellitus, a history of hypercholesterolemia, and the presence of other 

cardiovascular disease risk factors he was cleared for duty. The information available to the NIOSH 

investigator suggests that the firefighter should not have been cleared for duty without additional 

testing according to NFPA 1582 guidance.

ESTs can be used to screen for and identify occult coronary heart disease (CHD). However, 

recommendations for conducting ESTs on asymptomatic individuals without known heart disease are 

varied. The following paragraphs summarize the positions of widely recognized organizations on this 

topic.
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NFPA 1582 recommends an EST be performed “as clinically indicated by history or symptoms” and 

refers the reader to its Appendix A [NFPA 2013a]. Items in Appendix A are not standard requirements, 

but are provided for “informational purposes only.” Appendix A recommends using submaximal (85% 

of predicted heart rate) stress tests as a screening tool to evaluate a firefighter’s aerobic capacity. 

Maximal (i.e., symptom-limiting) stress tests with imaging should be used for firefighters with the 

following conditions: 

• abnormal screening submaximal tests 

• cardiac symptoms 

• known coronary artery disease (CAD) 

• one or more risk factors for CAD (in men older than 45 and women older than 55) 

Risk factors are defined as hypercholesterolemia (total cholesterol greater than 240 milligrams per 

deciliter), hypertension (diastolic blood pressure greater than 90 mmHg), smoking, diabetes mellitus, 

or family history of premature CAD (heart attack or sudden cardiac death in a first-degree relative less 

than 60 years old). 

The American College of Cardiology/American Heart Association (ACC/AHA) has also published 

exercise testing guidelines [ACC/AHA 2002]. The ACC/AHA guideline states the evidence is “less 

well established” (Class IIb) for the following groups: 

• persons with multiple risk factors (defined similarly to those listed by the NFPA) 

• asymptomatic men older than 45 years and women older than 55 years: 

o who are sedentary and plan to start vigorous exercise 

o who are involved in occupations in which impairment might jeopardize public safety 

(e.g., firefighters) 

o who are at high risk for CAD due to other diseases (e.g., peripheral vascular disease and 

chronic renal failure) 

The U.S. Department of Transportation provides guidance for those seeking medical certification for a 

commercial driver’s license. An expert medical panel recommended exercise tolerance tests (stress 

tests) for asymptomatic “high risk” drivers [Blumenthal et al. 2007]. The panel defines high risk 

drivers as those with any of the following: 

• diabetes mellitus 

• peripheral vascular disease 

• age 45 and above with multiple risk factors for CHD 

• Framingham risk score predicting a 20% coronary heart disease event risk over the next 

10 years 
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The U.S. Preventive Services Task Force (USPSTF) does not recommend stress tests for asymptomatic 

individuals at low risk for CHD events. For individuals at increased risk for CHD events, the USPSTF 

found “insufficient evidence to recommend for or against routine screening with EKG, exercise 

tolerance test, or electron beam computerized tomography scanning...” Rather, they recommend the 

diagnosis and treatment of modifiable risk factors (hypertension, high cholesterol, smoking, and 

diabetes) [USPSTF 2004]. The USPSTF does note that “For people in certain occupations, such as 

pilots, and heavy equipment operators (for whom sudden incapacitation or sudden death may endanger 

the safety of others), consideration other than the health benefit to the individual patient may influence 

the decision to screen for coronary heart disease.” 

The FF/P was older than 45 years of age, had diabetes mellitus, and had multiple risk factors for CHD. 

Given these conditions, a symptom limiting EST was indicated according to the positions of several 

widely recognized organizations. Although the occupational physician conducting the FD medical 

evaluation recommended that the FF/P discuss a treadmill test with his physician, the FF/P was cleared 

for duty without it. Had a symptom limited exercise test been performed perhaps his coronary artery 

disease could have been detected and treated. 

Recommendations

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

with NFPA 1582, Standard on Comprehensive Occupational Medical Program for 

Fire Departments.

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

1582 and in the IAFF/IAFC Fire Service Joint Labor Management Wellness/Fitness Initiative [IAFF, 

IAFC 2008; NFPA 2013a]. These evaluations are performed to determine a firefighter’s medical 

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

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

include screening testing for coronary artery disease in individuals with cardiovascular disease risk 

factors and should include appropriate testing for individuals with diabetes mellitus before they are 

cleared for duty. 

Recommendation #2: Incorporate ESTs into the fire department medical evaluation program for 

firefighters at increased risk for coronary heart disease. 

NFPA 1582, the IAFF/IAFC Fire Service Joint Labor Management Wellness/Fitness Initiative, and the 

ACC/AHA recommend an EST for male firefighters older than 45 with one or more coronary artery 

disease risk factors [ACC/AHA 2002; IAFF, IAFC 2008; NFPA 2013a]. The FF/P was over the age of 

45 and had multiple risk factors for coronary heart disease (high blood pressure, diabetes mellitus, 

obesity, and high cholesterol). A symptom-limiting ESTs may have identified his underlying coronary 

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

firefighters.

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

disease and improve cardiovascular capacity is found in NFPA 1583, Standard on Health-Related 

Fitness Programs for Fire Fighters, the IAFF/IAFC Fire Service Joint Labor Management 

Wellness/Fitness Initiative, the U.S. Fire Administration Health and Wellness Guide for the Volunteer 

Fire and Emergency Services, and in Firefighter Fitness: A Health and Wellness Guide [IAFF, IAFC 

2008; NFPA 2015; Schneider 2010; USFA 2009]. Worksite health promotion programs have been 

shown to be cost effective by increasing productivity, reducing absenteeism, and reducing the number 

of work-related injuries and lost workdays [Aldana 2001; Stein et al. 2000]. Fire service health 

promotion programs have been shown to reduce coronary heart disease risk factors and improve fitness

levels, with mandatory programs showing the most benefit [Blevins et al. 2006; Dempsey et al. 2002; 

Womack et al. 2005]. 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 non-occupational healthcare costs [Kuehl et al. 2013]. The FD does not 

have a wellness/fitness program. The FD has exercise equipment available for its members and FF are 

permitted to exercise on duty. Nonetheless, NIOSH recommends a mandatory wellness/fitness 

program to ensure all members receive the benefits of a wellness/fitness program. 

Recommendation #4: Perform an annual physical performance (physical ability) evaluation.

NFPA 1500 recommends fire department members who engage in emergency operations be annually 

evaluated and certified by the FD as having met the physical performance requirements identified in 

paragraph 10.2.3 of the standard [NFPA 2013b]. This is recommended to ensure firefighters are 

physically capable of performing the essential job tasks of structural firefighting. The physical ability 

test could be performed as part of the FD’s annual training program.

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Investigator Information

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

Program, Cardiovascular Disease Component located in Cincinnati, Ohio. Denise L. Smith, Ph.D, led 

the investigation and coauthored the report. Dr. Smith is professor of Health and Exercise Sciences, 
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and Director of the First Responder Health and Safety Laboratory at Skidmore College. She is a 

member of the NFPA Technical Committee on Occupational Safety and Health. Dr. Smith was 

working as a contractor with the NIOSH Fire Fighter Fatality Investigation and Prevention Program, 

Cardiovascular Disease Component during this investigation. Dr. Wendi Dick, Team Lead for Cardiac 

and Medical LODD Investigations, provided medical consultation and contributed to the 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 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.
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Appendix A

Autopsy Findings

• Hypertension (clinical history) 

o Cardiomegaly with left ventricular dilation (heart weighed 683 grams; predicted normal 

weight is 479 grams [ranges between 363 and 633 grams as a function of sex, age, and 

body weight]) [Silver and Silver 2001]

o Left ventricular wall – 1.5 cm

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

o Right ventricular wall – 0.8 cm

 Normal at autopsy is 0.2–0.7 cm with an average of 0.35–0.39 cm [Hutchins and 

Anaya 1973; Murphy et al. 1988]

o Left ventricular chamber dilation (5.0 cm)

• Coronary artery and aortic atherosclerosis

o Calcified atherosclerosis in right coronary artery and left anterior descending coronary 

artery

o 60% stenosis of the right coronary artery

o 80% stenosis of the left anterior descending coronary artery

• Mild to moderate atherosclerotic plaque in descending aorta

• Cholesterolosis of the gallbladder

• Normal cardiac valves

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

• Negative blood test for drugs of abuse

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at autopsy. Johns Hopkins Med J 133(2):96–106.

Murphy ML, White HJ, Meade J, Straub KD [1988]. The relationship between hypertrophy and 

dilatation in the postmortem heart. Clin Cardiol 11(5):297–302, 

https://doi.org/10.1002/clc.4960110505. 
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