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Executive Summary

In December 2015, a 49-year-old male firefighter (FF) responded to a medical call. He drove an engine 

assigned to assist an ambulance. While doing chest compressions on a cardiac arrest victim, the FF 

complained of being tired. His lieutenant (LT) had him stop and sit down. The FF then complained of 

chest pain. The LT summoned another ambulance. On entering the ambulance, the FF became 

unresponsive. The ambulance crew began cardiopulmonary resuscitation and advanced life support. 

They transported the FF to the hospital emergency department. There, advanced life support care 

continued until the FF was pronounced dead. 

The death certificate listed coronary artery thrombosis as the immediate cause of death and coronary 

atherosclerosis as the underlying cause of death. The autopsy revealed a thrombus that completely 

occluded the left anterior descending coronary artery. National Institute for Occupational Safety and 

Health investigators conclude that the emergency response and physical exertion of doing chest 

compressions triggered a heart attack. 

Key Recommendations

• Phase in a mandatory comprehensive wellness and fitness program for firefighters.
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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 firefighter initiative that resulted in the NIOSH Fire Fighter Fatality Investigation and Prevention Program

(FFFIPP), which examines line-of-duty deaths or on-duty deaths of firefighters to assist fire departments, firefighters, the fire service, and others to prevent 

similar firefighter 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 December 4, 2015, a 49-year-old firefighter (FF) suffered a heart attack while performing 

cardiopulmonary resuscitation (CPR) on a cardiac arrest victim. The U.S. Fire Administration notified 

the National Institute for Occupational Safety and Health (NIOSH) of this fatality on December 7, 

2015. NIOSH contacted the affected fire department (FD) on December 7, 2015 and again on June 20, 

2016, to gather additional information and to initiate the investigation. On June 24, 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

• Lieutenant (LT) and FF on the engine crew on which the FF was working 

• Paramedic on responding ambulance 

• Union president 

• FF’s widow

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 December 4, 2015, a 49-year-old male career FF reported for duty at 0700 hours. The FF was the 

engineer/driver on the engine. During the morning he participated in daily chores and responded to a 

minor medical call. At approximately 1440 hours, the engine and its crew were dispatched to assist the 

ambulance with a cardiac arrest at a retail store. CPR had been initiated by bystanders and the 
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ambulance crew took over patient care when they arrived. The FF and other members of the engine 

crew assisted the ambulance crew in loading the patient into the ambulance and assisted with patient 

care. The FF had been performing chest compressions for approximately 5–6 minutes when he stated 

that he was tired. His LT noticed that the FF’s face was red and that he was sweating profusely. The 

LT had the FF take off his coat and sit down while another crew member took over compressions. The 

FF complained of chest pain. When the FF was asked if he thought chest pain was muscular in nature 

due to compressions. He did not have a clear answer. The LT had the FF step out of the ambulance into 

the cooler air (41°F, 85% humidity, winds out of the south at 9.2 miles per hour; wind chill of 36°F) 

[Weather Underground no date] and he called for a second ambulance. The LT stayed with the FF, 

noticing that the FF’s color seemed to improve but he was agitated. The second ambulance arrived at 

1457 hours. The FF walked to the ambulance, stepped into the back, and sat on the cot. Emergency 

medical services (EMS) personnel noted that he was alert and oriented but appeared pale and was 

sweating heavily. The FF reported that he had experienced substernal chest pain that radiated down his 

arm. Just as the FF finished his sentence, he began to have seizure like activity and became 

unresponsive. EMS personnel requested additional personnel and initiated CPR and advanced cardiac 

life support. The electrocardiogram (ECG) revealed pulseless electrical activity. Oxygen was provided 

by bag-valve mask. A King airway was secured and epinephrine was provided via an intraosseous line. 

The ambulance departed the scene at 1505 hours and arrived at the ED at 1510 hours. 

The FF arrived at the ED with no pulse and in asystole (no heart rhythm). He was intubated and 

provided with cardiac medications but remained in asystole. Full cardiac life support measures were 

continued in the ED for over 30 minutes without change in clinical status. An ultrasound confirmed the 

absence of a spontaneous heart movement. At 1545 hours, CPR was discontinued and the FF was 

pronounced dead. 

Medical Findings

The death certificate and autopsy reports were completed by the County Medical Examiner. They 

identified a large intracoronary thrombus in the left anterior descending coronary artery as the cause of 

death due to underlying coronary atherosclerosis and noted obesity as a contributing condition. The 

autopsy revealed approximately 70% narrowing of the left anterior descending artery due to 

atherosclerotic plaque, a slightly enlarged heart (467 grams), and left ventricular hypertrophy 

(1.5 centimeters [cm]). See Appendix A for a more detailed description of autopsy findings. 

The FF had a history of hypertension, hyperlipidemia, and hyperglycemia, and ongoing gastric reflux 

and heartburn. He also had several bouts of sinus infections and bronchitis and orthopedic problems 

over the past 3 years. The FF regularly saw a primary care physician (PCP) to monitor and treat his 

medical conditions. He was taking medication for hypertension, but was not taking medication for 

hyperlipidemia or hyperglycemia. At his last PCP visit on September 9, 2015 (a follow-up visit for 

bronchitis and acute sinusitis), his blood pressure was 130/100 millimeters of mercury (mmHg) 

(normal resting systolic is 90–119 mmHg and normal resting diastolic is 60–79 mmHg).

The FF experienced chest pains in January 2015 and was admitted to the hospital for evaluation. Blood 

work revealed troponin and d-dimer values (enzymes used as markers of a heart attack) that were 
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within normal limits. A chest X-ray found normal sized heart and vessels and no acute 

cardiopulmonary findings. An echocardiogram reported normal left ventricular size (although the 

measurements recorded in the results include a normal left ventricular wall size [.8 cm] and a 

thickened septal wall [1.8 cm]) and normal systolic function with a normal ejection fraction of 60%–

65%. A myocardial perfusion study found no significant perfusion defects. The FF completed an 

exercise stress test (EST) using the Bruce protocol and exercised for 9 minutes (attaining 

approximately 10 metabolic equivalents [METs]), achieving a maximal heart rate of 92 beats per 

minute (bpm) (87% of age-predicted maximum). The EST was negative for angina symptoms and 

diagnostic ischemic ECG changes. 

The FF had his last FD medical evaluation in July 2015. At that time, laboratory tests showed a total 

blood cholesterol of 142 milligrams per deciliter (mg/dL) (desirable < 200 mg/dL), triglycerides of 

141 mg/dL (normal < 150 mg/dL), high-density lipoprotein (HDL) cholesterol of 38 mg/dL (normal 

> 40 mg/dL) [NCEP 2002], and blood glucose of 106 mg/dL (normal 70–100 mg/dL). The FF was 

cleared for full firefighting duty. 

The FF was a non-smoker with a family history of cardiovascular disease. He had recently been 

involved in a work hardening program for a shoulder injury. Based on autopsy, he was 71 inches tall 

and weighed 262 pounds, giving him a body mass index of 36.5 kilograms per meter squared [CDC 

2015]. 

Fire Department

At the time of the NIOSH investigation, the FD consisted of approximately 30 uniformed personnel 

working out of two fire stations. It served a population of approximately 20,000 in a geographic area of 

18 square miles. In 2015, the FD responded to over 3,500 incidents, including 1,460 fire calls and more 

than 2,000 rescue and emergency medical 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 given, 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 are placed on a 24-hour shift (24 hours on duty, 72 hours off duty) 

and are on probation for 1 year. The FF was certified as a Firefighter II and driver/operator and was a 

licensed paramedic. He had been a FF for 25 years and had been employed by his current FD for 

13 years. 

Preplacement and Periodic Medical Evaluations 

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

contract occupational medical group. Components of this evaluation include the following: 
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• Complete medical history

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

• Complete blood count with lipid panel 

• Urinalysis

• Urine drug screen 

• Audiogram 

• Vision test

• Respirator use questionnaire

• Spirometry

• Resting ECG 

• Chest x-ray

Periodic medical evaluations are provided annually to all members and contain the same components 

listed above except that a drug screen is not performed on all FFs. 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 contracted health provider also 

makes determinations on return to work after an injury or illness. 

Wellness/Fitness Programs

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

Association of Fire Fighters, International Association of Fire Chiefs (IAFF/IAFC) Wellness Fitness 

Initiative [IAFF, IAFC 2008]. The FD has exercise equipment available in the stations and allows 

firefighters to work out in the afternoon. 

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 

2015; NHLBI no date]. The FF had hypertension, hyperlipidemia, and hyperglycemia; he was obese

(on the basis of his body mass index measurement of 36.5). 

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 
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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]. Establishing a recent (acute) heart attack requires any of the 

following: characteristic ECG changes, elevated cardiac enzymes, or coronary artery thrombus. In this 

case, the FF had a thrombus that occluded the left anterior descending coronary artery. 

Firefighting and Sudden Cardiac Death

Heart attacks and sudden cardiac death can be triggered by heavy physical exertion [Albert et al. 2000, 

Mittleman 1993; Willich 1993]. Among firefighters, sudden cardiac events have been associated with 

or triggered by alarm response, fire suppression, and heavy exertion during training (including physical 

fitness training) [Kales et al. 2003, 2007; NIOSH 2007]. In response to a medical call, the FF helped 

load the patient into the ambulance and provided chest compressions for 5–6 minutes. NIOSH 

concludes that the emergency response and physical exertion of doing chest compressions triggered a 

heart attack. 

Left Ventricular Hypertrophy

On autopsy, the FF was found to have LVH with the left ventricular wall measuring 1.5 cm. 

Hypertrophy of the heart’s left ventricle is a relatively common finding among individuals with longstanding hypertension, a heart valve problem, or chronic cardiac ischemia (reduced blood supply to the 

heart muscle) [Siegel 1997]. Left ventricular hypertrophy (LVH), one aspect of hypertensive 

cardiovascular disease, is associated with increased risk for sudden cardiac death [Levy et al. 1990]. In 

this case, the FF had had an echocardiogram 15 months earlier. In that exam, the physician reported no 

evidence of left ventricular hypertrophy despite a left ventricular wall thickness of 0.8 cm and a septal 

wall thickness of 1.8 cm (normal 0.6–1.0 cm). It is unclear why the left ventricular wall was measured 

as 0.8 cm via echocardiography only 15 months prior to the fatal incident. This may have been due to 

technical difficulties in imaging the heart or it may reflect rapid changes in left ventricular wall 

thickness. 

Occupational Medical Standards for Structural Firefighters 

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

firefighters, the National Fire Protection Association (NFPA) developed NFPA 1582, Standard on 

Comprehensive Occupational Medical Program for Fire Departments [NFPA 2013]. This voluntary 

industry standard provides the components of a preplacement and annual medical evaluation and 

medical fitness for duty criteria. The FF had his last yearly medical exam in July 2015. In the absence 

of significant findings, he was cleared for full firefighting duty. 

Recommendations

Recommendation #1: Phase in a mandatory comprehensive wellness and fitness program for 

firefighters.

Although the FD has extensive exercise equipment in both stations and provides time for firefighters to 

exercise, it does not have a mandatory wellness/fitness program. Guidance for fire department 

wellness/fitness programs to reduce risk factors for cardiovascular disease and improve cardiovascular 
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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]. 

References

AHA [2016]. Understand your risks to prevent a heart attack. Dallas, TX: American Heart Association, 

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

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

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

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

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

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

literature. Am J Health Promot 15(5):296–320, http://dx.doi.org/10.4278/0890-1171-15.5.296. 

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

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

CDC (Centers for Disease Control and Prevention) [2015]. Adult BMI calculator. 

http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.ht

ml. 

Dempsey WL, Stevens SR, Snell CR [2002]. Changes in physical performance and medical measures 

following a mandatory firefighter wellness program. Med Sci Sports Exerc 34(5):S258, 

https://www.researchgate.net/deref/http%3A%2F%2Fdx.doi.org%2F10.1097%2F00005768-

200205001-01445. 

IAFF, IAFC [2008]. 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.

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

coronary heart disease: a case control study. Environ Health 2(1):14, https://doi.org/10.1186/1476-

069x-2-14. 
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Kales SN, Soteriades ES, Christophi CA, Christiani DC [2007]. Emergency duties and deaths from 

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

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

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

PHLAME wellness programme on firefighter injury. Occup Med 63(3):203–209,

https://doi.org/10.1093/occmed/kqs232. 

Libby P [2013]. Mechanisms of acute coronary syndromes and their implications for therapy. N Engl J 

Med 368(21):2004–2013, http://dx.doi.org/10.1056/NEJMra1216063.

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

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

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

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

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

http://dx.doi.org/10.1056/NEJM199312023292301.

NCEP [2002]. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on 

Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult treatment Panel III). 

NIH Publication No. 02-5215. National Institutes of Health, National Heart, Lung, and Blood Institute. 

Washington, DC: Government Printing Office.

NFPA [2013]. NFPA 1582. Standard on comprehensive occupational medical program for fire 

departments. Quincy, MA: National Fire Protection Association. 

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

National Fire Protection Association. 

NHLBI [no date]. Who is at risk for coronary heart disease? Bethesda MD: National Institutes of 

Health, National Heart, Lung and Blood Institute, https://www.nhlbi.nih.gov/health-topics/coronaryheart-disease. 

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

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

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

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

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

Publishers.

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

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

program. J Occup Environ Med 42(12):1148–1155, https://doi.org/10.1097/00043764-200012000-

00005. 
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USFA [2009]. Health and wellness guide for the volunteer fire and emergency services. Emmitsburg, 

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

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

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

http://www.wunderground.com/history. 

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, 

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. Wendi Dick, MD, MSPH, provided 

medical consultation and contributed to the report. Dr. Dick is Medical Officer for the Cardiac/Medical 

Fatalities Component in Cincinnati. 

Disclaimer

Mention of any company or product does not constitute endorsement by the National Institute for 

Occupational Safety and Health (NIOSH). In addition, citations to 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

• Atherosclerotic Cardiovascular Disease 

o Proximal aspect of the left anterior descending coronary artery is occluded by an 

intraluminal thrombosis

o 70% luminal narrowing of left anterior descending coronary artery due to 

atherosclerosis

• Cardiomegaly with left ventricular dilation (heart weighed 467 grams; predicted normal weight 

is 425 grams [ranges between 322 and 561 grams as a function of sex, age, and body weight]) 

[Silver and Silver 2001] 

o Left ventricular wall thickness (1.5 cm)

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

 Normal by echocardiographic measurement is 0.6–1.0 cm [Connolly and Oh 

2012]

o Interventricular wall thickness (1.2 cm)

• Pulmonary congestion and edema

• Normal cardiac valves

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

• Negative blood test for drugs and alcohol

REFERENCES

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

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

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

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

Elsevier Saunders.

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

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

PA: Churchill Livingstone.