Firefighters tackle a wide variety of challenging operational scenarios and suffer significant stress and physiological demands during the discharge of their duties.¹ Because the majority of modern fire department emergency calls are for EMS, it is possible for physicians to be less familiar with the fire and rescue operations of the department they work with. EMS physicians must be aware of the unique operational challenges of firefighting and the potential role that the physician plays on the fire ground and their duties as the fire department physician.

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  Understand basic fire ground operations, including training requirements, fitness requirements, firefighter protective gear, and various tasks performed on the fire ground.

  
  
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  Understand basic fire ground rehabilitation, including the need for rehab, firefighter physical fitness, the rehab station itself, and common medical/traumatic injuries.

While on the fire ground the firefighter may be asked to perform a multitude of tasks, including fire suppression, search and rescue, ventilation, and salvage and overhaul (Box 65-1).² Fire suppression is the actual spraying of water and/or chemicals onto and around the fire, extinguishing it. Search and rescue is a systematic search of the entire building for victims. It consists of a primary search, which is rapid but thorough, and a secondary search, which is a more thorough search performed only after the fire is under control. Ventilation is the removal of heated air, smoke, and gases from the structure that is then replaced with cooler air. Ventilation increases firefighter visibility and decreases hot, toxic gases created by the fire. Finally, salvage and overhaul is an attempt to minimize property damage from the fire and the associated suppression activities, while also trying to detect hidden fires and determine the point and cause of origin.

FIREFIGHTER TRAINING REQUIREMENTS

Becoming a firefighter is arduous journey that begins at the state and local levels. Training requirements are on a state-to-state basis, with additional training provided by the local jurisdiction. There is, however, the National Fire Protection Association (NFPA), which is a national organization created to “reduce the world wide burden of fire and other hazards on the quality of life by providing and advocating consensus codes and standards, research, training, and education.”³ NFPA 1001 is the standard for firefighter training which describes the various tasks and knowledge that each firefighter should have.⁴ The ProBoard Fire Service Professional Qualifications System is a national organization that certifies firefighters according to NFPA standards and has been adopted by 30 states, thus allowing firefighters to transfer their credentials across state lines.

Firefighting is a physically demanding job,⁵ with an average heart rate of 179 during the most demanding tasks.⁶ As such, the International Association of Fire Fighters (IAFF) and the International Association of Fire Chiefs (IAFC) have created the Candidate Physical Ability Test (CPAT), a screening test which is designed to “ensure that all fire fighter candidates possess the physical ability to complete critical tasks effectively and safely.”⁷ The CPAT recreates a similar VO₂ Max (a measure of their maximum oxygen consumption, and thus overall physical fitness) to that seen in firefighter simulations.⁸ Also, the higher a candidate’s VO₂ Max, the more likely they are to pass the CPAT9; thus the CPAT appears to be an effective screening tool for firefighter physical fitness.

FIREFIGHTER PROTECTIVE EQUIPMENT

Firefighters are required to wear personal protective equipment (PPE) while performing their duties. NFPA 1971, NFPA 1981, NFPA 1851, and NFPA 1852 describe firefighter PPE and their maintenance. A complete description of PPE is outside the scope of this chapter; however, Box 65-2 lists the basic components.¹⁰

While protecting the firefighter from extreme conditions, PPE does present some limitations to the user. The SCBA itself limits peripheral vision by as much as 28%¹¹; limits communication, mobility,¹² and increases weight. The SCBA also has a limited air supply, with time frames depending on the type of cylinder and manufacturer. As a result of the thermal and moisture barriers of the coat and trousers, firefighter PPE also creates “microclimates” that are warmer and wetter, with temperatures of 48°C (118°F) and 100% relative humidity surrounding the firefighter.¹³ PPE increases energy consumption and decreases VO₂ Max, mostly as a result of the extra weight the firefighter is now carrying plus the gears’ inability to dissipate heat.^14–16 All of this extra heat, humidity, restrictions in vision and mobility, and weight puts an additional mental, cardiovascular, and thermoregulatory strain on the firefighter.^17,18

THE NEED FOR REHAB

The need for firefighter rehab at the scene is easily explained when you consider the morbidity and mortality of firefighting. Each year, tens of thousands of firefighters are injured during the course of their duties; this includes training, responding to or returning from an emergency, or at the fire ground. In 2002 alone, there were an estimated 80,800 injuries to firefighters.²⁰ The most common injuries include sprains, strains, and open wounds, with the most common causative factor being overexertion.²¹ As expected, larger incidents lead to more injuries.²²

Unfortunately, many firefighters also lose their lives as a result of their job. The most recent data from 2009 showed that 90 firefighters died as a result of firefighting duties, including those that suffered a heart attack or stroke within 24 hours of an emergency response or training activity.²³ The most common cause of death includes cardiac arrest, trauma, asphyxiation, and motor vehicle accidents (see Figure 65-1), with most deaths caused by overexertion.^24,25 The typical line-of-duty death is a low-ranking male volunteer firefighter, at a structure fire, and is caused by overexertion.^25,26 Interestingly, the most common cause of death changes based on age; younger firefighters are more likely to die from trauma, while older firefighters are more likely to die from cardiac arrest.^25,26 Additionally, firefighters are more likely to die from cardiac arrest responding to the alarm and during fire suppression than during other nonemergent duties,²⁶ probably a result of the increased cardiovascular demand of fire suppression activities.²⁷ Firefighters are also more likely to die from cardiac arrest if they smoke, have hypertension, have coronary artery disease (CAD), or are over 45 years old.²⁸ Some of these same risk factors actually predict death from cardiac arrest as well, including smoking, CAD, and hypertension.²⁹ Lastly, firefighting as an occupation does not appear to have higher rates of CAD, but seems to be the result of conventional and usually modifiable CAD risk factors, including age, smoking, diastolic blood pressure, and family history.³⁰

FIREFIGHTER FITNESS FOR DUTY AND PHYSICAL FITNESS

The way to prevent morbidity and mortality is to adequately screen firefighters during the initial medical clearance, and to encourage physical fitness and overall well-being.³¹ NFPA 1582 was created for the purpose of firefighter medical screening. It includes a comprehensive list of medical disorders that pose a “significant risk to safety and health of the person or others.”³² These include medical disorders like craniofacial abnormalities, low visual acuity, recurrent syncope, uncontrolled seizures, etc. The initial and annual medical workup recommended by the NFPA includes a CBC, BMP, LFTs, lipid panel, urine analysis, audiology screening, pulmonary function testing, ECG, mammography or PSA testing, routine immunizations, HIV testing, colon cancer screening, a chest x-ray every 5 years, and heavy metal screening if needed.³³

Given the extreme cardiovascular workload experienced by firefighters, a minimum VO₂ Max has been recommended by the NFPA, along with multiple other sources.^3,33,34 In addition, routine cardiac stress tests have been advocated for firefighters with two or more risk factors for CAD (ie, smoking, diabetes, hypertension, hyperlipidemia, physical inactivity, obesity, or strong family history).^32,33 Screening for CAD in firefighters has been shown to reduce overall medical costs.³¹ A recent study recommends that these cardiac stress tests be limited by exhaustion or age-predicted maximum heart rate, as opposed to the 85% submaximal tests that are commonly used for screening purposes.³⁵

By virtue of the screening process, firefighters generally have a higher level of physical fitness than the general population³⁶ and firefighter physical fitness is associated with an improved metabolic profile.³⁷ Firefighting taxes all aspects of physical fitness38; and physical fitness influences performance of firefighter tasks,³⁹ as firefighters with higher physical fitness completed tasks quicker.⁴⁰ Unfortunately, a firefighter’s self-perception of their own physical fitness is not associated with their actual physical fitness.⁴¹ Therefore, the NFPA created standard 1583 to help define physical fitness programs for fire department members^42–44 (Box 65-3). One study showed that the physical fitness of firefighters could be substantially improved in as little as 16 weeks.⁴⁵

Maintaining medical well-being is also discussed in NFPA 1582. Unfortunately as firefighters age, they have a similar rate of decline in cholesterol, hypertension, and body composition as compared to the general public.³⁷ But they also have a higher prevalence of obesity, high LDL, and low HDL cholesterol as they age.⁴⁶ This higher rate of obesity has been linked to higher rates of CAD risk factors in firefighters as well.⁴⁷ Furthermore, obesity was even more prevalent when assessed by percentage body fat, debunking the myth that firefighters were misclassified as obese simply because they were muscular.⁴⁸ As such, some authors have recommended that annual medical screening should “proactively target cardiovascular risk factors.”⁴⁷

THE REHAB STATION

The fire ground rehab station is specifically set up to provide rest for firefighters who have been working for extended periods of time. NFPA 1584 was created to describe the rehabilitation process, which focuses on nine key areas⁴⁹ (Box 65-4):