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1 Running Head: PROTECTING THOSE WHO PROTECT US 1 Protecting Those Who Protect Us: Taking Steps to Reduce Sudden Cardiac Deaths among Firefighters in the New River Valley Carolyn M. Tucker Radford University

2 PROTECTING THOSE WHO PROTECT US 2 Protecting Those Who Protect Us: Taking Steps to Reduce Sudden Cardiac Deaths among Firefighters in the New River Valley Introduction They are guardians. They stand ready to run to our aid in a heartbeat whether it is an accidental fire, a car accident, or even a terrorist attack. Firefighters: they serve in an extremely dangerous profession at the risk of their own lives, and they do this most often for people they have never even met. Even more amazing is that many of them do all of this with no monetary compensation. Many are volunteers, and this is the case in the New River Valley. In this rural part of Virginia, the majority of firefighters are volunteers with other full-time jobs. Knowing this, it is saddening to learn that about 32% of deaths that occur during firefighters response to an emergency are not due to a building collapsing on top of them or smoke inhalation but to sudden cardiac death (Kales, Soteriades, Christophi & Christiani, 2007, p. 1210). This is a problem that needs to be addressed. A possible cause for this high number of sudden cardiac deaths is the large number of volunteers. These are not professional firefighters, so they do not receive the training and physical preparation that a paid firefighter does. When they run into a high stress situation with forty or more pounds of equipment and little physical preparation for this, it is no wonder that their heart gives out. A lack of knowledge of this topic may also be to blame. Even paid firefighters are rarely required to pass physical tests or perform physical training. With such a stressful duty, it is easy to overlook one s own health as a priority and get in the habit of an unhealthy lifestyle. These emergency workers fill a very important role in society and we need them to provide a very valuable service to the people of the New River Valley, therefore it is important that they take care of themselves so when a tragedy hits they are able to focus on their victims and do not become a victim themselves.

3 PROTECTING THOSE WHO PROTECT US 3 Definition of Target Population In order to effectively address the issue, the target population must first be clearly defined. For this paper, the firefighter population of the New River Valley (NRV) was chosen. The NRV consists of Floyd, Giles, Montgomery, and Pulaski counties and the independent City of Radford (New River Valley, 2010). This mountainous region is mostly rural with about 68% of its land being forested (New River Valley, 2010). Of the NRV s 941,162 acres of land, 359,227 were used for farm land in 2007, but this number is slowly declining (New River Valley, 2010). Its population in 2009 was about 172,770 people with an average income per family of about $52-$62 thousand per year in 2010 (New River Valley, 2010). Since the New River Valley has a mostly rural population, its firefighter population is mostly volunteer. An interview of five different fire stations in the NRV indicated a rate of roughly 80-90% volunteer firefighters based on statistics at each station and information on New River Valley fire departments from the interviewees. Lieutenant Danny Yopp of the Christiansburg Fire Department reported that his station consisted of thirty-five volunteers and one paid firefighter: the fire chief (personal communication, March 23, 2012). Fire Inspector Whitt of Blacksburg reported fifty volunteers and two paid firefighters (personal communication, March 26, 2012). This is typical of most Montgomery County departments because all Montgomery departments are volunteer; the only paid members are usually chiefs or other officers (S. Palmer, personal communication, March 26, 2012). Volunteers usually have less training; an article in the Roanoke Times reported on the turnover of volunteer firefighters in southwest Virginia saying that each year the number of volunteers gained was nearly equal to those lost (Valencia, 2011). This shows that many volunteers in the area are often relatively new to firefighting.

4 PROTECTING THOSE WHO PROTECT US 4 These interviews also revealed that few or no physical tests are required and no physical training is implemented to ensure that the hearts of these firefighters are prepared for the strenuous work required when responding to a call. Volunteer Peyton Ellis of the Radford Fire Department revealed that the paid staff members there are required to do one hour of exercise per shift, but not the volunteers (personal communication, March 23, 2012). Captain Hughes of the Pulaski Fire Department said that they recently implemented a yearly physical fitness test, a physical examination, and their station has an exercise program that recommends an hour of cardio exercise per day, but this is not required (personal communication, March 24, 2012). Only one interviewee reported that his department received classes on heart health promotion or awareness, and no departments had height/weight standards that they were required to meet. The number of incidents that firefighters must respond to is increasing. In Virginia, from 2006 to 2011, the number of incidents that firefighters responded to rose from 611,118 to 726,804, rising steadily each year, and 9 firefighters were lost in the line of duty during this time (Virginia Department, 2012). With these increasing numbers, it is becoming more and more important to take steps to reduce the risk of a sudden cardiac death of firefighters in the line of duty to be able to respond to the rising needs. Potential Consequences There are many possible consequences of sudden cardiac deaths among firefighters in the line of duty. Initially, if the firefighter experiences a heart attack when he or she runs into an emergency scene to try to help the victims there, then he or she will be unable to help them. This can result in the loss of the firefighter and victims. Not only is one firefighter not able to help the victims, but other firefighters also have stop to help their fallen friend which may take even more attention away from the victims possibly resulting in a much higher casualty or injury count at

5 PROTECTING THOSE WHO PROTECT US 5 the scene of the incident. This could also result in the community s loss of confidence in the ability of local firefighters to effectively respond to an emergency. However, there are more long term and far reaching consequences. A line of duty death results in more financial burden on local governments because they will then owe the firefighter s family health insurance and other benefits (Virginia Department, 2010). Experiencing the death of a fellow firefighter and friend may result in serious psychological consequences for the other firefighters in the department. A traumatic event such as the loss of a friend and co-worker may lead to psychological disturbances such as depression (Coifman and Bonanno, 2010). Some people, around 10-15%, may suffer long term disturbances including grief and depression (Coifman and Bonanno, 2010, p. 480). Publicizing the death of a local firefighter may also discourage civilians from volunteering to serve as a firefighter which may result in a smaller local firefighting force. Even if a firefighter does not die, if he or she suffers a serious cardiac event, as is likely to occur while responding to an emergency call, he or she is still likely to count as a loss to the department. It is unlikely that they will be able to recover enough to return to their previous position and continue fighting fires and responding to emergency calls. Methods of Prevention A review of the literature reveals a variety of possible prevention methods that may be used to address the issue of sudden cardiac death among firefighters. When examining the strategies and services available, it is important to remember to include primary, secondary, and tertiary methods of prevention. Once a thorough examination of the methods suggested in the literature has been performed, gaps can be identified in the methods already in place, and changes can be made to address the issue.

6 PROTECTING THOSE WHO PROTECT US 6 Primary prevention will be examined first. Kunadharaju, Smith, and Dejoy (2011) came to conclusion that one of the biggest needs was for the implementation of a fitness and wellness program for firefighters (p. 1172). A healthy diet and exercise can help to maintain a healthy weight and a strong heart; obesity has proven to have serious risks related to cardiovascular disease, and avoiding obesity would be a large step toward preventing sudden cardiac death by promoting heart health (Pourier et al., 2006). Allen and Dennison (2010) reported that an internet-based cardiovascular risk factor management led by a nurse showed client improvement in a number of areas including weight loss, blood pressure, cholesterol and triglyceride levels, amount of exercise per week, and fat intake (p. 212). If the major components of a healthy lifestyle were emphasized in the lives of firefighters, this would assist in empowering them to take care of their own health and take steps to reduce risks to their heart health such as healthy eating, regular exercise, adequate regular rest, and smoking avoidance and cessation. Another aspect of primary prevention is ensuring that each firefighter is proficient in first aid and cardiopulmonary resuscitation (CPR). All firefighters in Virginia are required to be trained in these areas (Virginia Department, 2011), but it is important to confirm their proficiency in the case that they will have to provide emergency care. Lick et al. (2011) reports on the importance of rapid initiation of CPR and its positive affect on outcome and survival rates. If a firefighter is proficient in the areas of first aid and CPR, he or she will be less likely to hesitate to recognize the situation and begin providing care quickly when such an event occurs. Secondary prevention will be examined next. Kunadharaju et al. (2011) identify more intensive medical screening for firefighters as one of the most important methods to prevent sudden cardiac deaths in the line of duty and recommends that firefighters be required to pass a pre-placement and annual physical exam by a qualified physician as well as a standardized

7 PROTECTING THOSE WHO PROTECT US 7 physical fitness test (pp. 1172,1175). Requiring a physical exam would ensure that each firefighter is not at an increased risk for a cardiac incident such as a myocardial infarction while performing activities necessary to fight fires and respond to emergency calls. Requiring each firefighter to pass a standardized physical fitness test would ensure that each firefighter is physically capable of carrying out the physical demands required by the profession without causing harm to themselves in the process. In addition, Kunadharaju et al. (2011) recommend that fire departments perform stress tests on firefighters with two or more factors that place him or her at an increased risk for coronary artery disease (p. 1175). Lastly, tertiary prevention will be examined. On the scene, initial prevention of cardiac death after a serious cardiac event has already begun is initiation of first aid and CPR training that all emergency responders receive. Lick et al. (2011) show that the earlier CPR is started, the greater the chance of survival and the higher the chance of a better neurological outcome (pp. 30,31). Also, the shorter the amount of time between sudden cardiac arrest and receiving defibrillation, the higher the chance of survival and a better neurological outcome (Lick et al., 2011). Therefore, once a life-threatening cardiac event has already begun, the goal is rapid initiation of first aid treatment. If blood is kept circulating, there will be less widespread cell death and a better overall outcome for the victim. Even outside of firefighting, many of these treatments are recommended for all members of the community. Lick et al. (2011) show the impact of educating the entire community on how to perform CPR and use automated external defibrillators (AEDs) on victims of sudden cardiac arrest. Survival rates of cardiac arrest victims, neurological outcomes, and even return of spontaneous circulation before professional medical care all improved when the community was educated on these topics (Lick et al., 2011, p. 30,31). Even nurses in hospitals are held to these

8 PROTECTING THOSE WHO PROTECT US 8 same standards of initial response to cardiac arrest that include immediate chest compressions and mechanical ventilation (Carpico & Jenkins, 2011). The difference is that nurses are held to a higher standard in proper performance of CPR, ventilation, and monitoring (Carpico & Jenkins, 2011). In addition, the same way that fitness and wellness programs would benefit firefighters, they would also benefit the general public and community health. Current Approaches to the Problem Currently, there is little being done among New River Valley Firefighters to specifically address the issue of sudden cardiac death. The interviews of NRV fire departments revealed a few measures being taken, but they vary among departments. The Radford Fire Department required that each paid firefighter perform an hour of aerobic exercise per shift (P. Ellis, personal communication, March 23, 2012). The Pulaski Fire Department has a physical fitness program that recommends each staff member perform an hour of aerobic exercise per day, but this is not enforced (J. Hughes, personal communication, March 24, 2012). Pulaski also has a required annual physical fitness test and physical exam that each firefighter must pass (J. Hughes, personal communication, March 24, 2012). The Blacksburg Fire Department requires paid employees to pass a physical exam before they are hired, and they have an exercise room with cardio equipment and weights (C. Whitt, personal communication, March 26, 2012). The Elliston Fire Department is the only department that has a yearly class on healthy lifestyles, and they also have a well-equipped exercise room (S. Palmer, personal communication, March 26, 2012). The Christiansburg Fire Department has pamphlets around the station promoting heart health and healthy lifestyles from the Virginia Department of Fire Programs (D. Yopp, personal communication, March 23, 2012). As mentioned earlier, Virginia requires all firefighters to be

9 PROTECTING THOSE WHO PROTECT US 9 CPR and first aid qualified, therefore all firefighters do have at least basic knowledge of these topics (Virginia Department, 2011). It is very disappointing to find so many gaps in the attention given to this issue. The two methods recommended to be of the highest importance by Kunadharaju et al. (2011), wellness and fitness programs and medical screenings, are not implemented by the majority of firefighter employers in the New River Valley (p. 1172). Only one interviewee mentioned having a fitness program, and this was only a recommended program; it was not required, and incentives were not offered. Required physical training was only reported in one department, but this was only required of paid employees, and no workout equipment was available at this department; the firefighters had to go to the local recreation center (P. Ellis, personal communication, March 25, 2012). All but one department did not require an annual physical fitness test. Very few screenings are in place throughout New River Valley fire departments, and annual physical exams were required by only two of the departments interviewed, and one of these departments only required paid firefighters to receive them. Nursing Roles Research has not revealed any specific nurse involvement in this particular issue. A large number of the recommendations of prevention methods however either require or would greatly benefit from nursing involvement. Allen and Dennison (2010) provide a number of nursing interventions that have shown improvements in patients with heart disease or at risk for heart disease: aerobic exercise programs and home visits, telephone follow-ups for case management, nurse-led disease management or heart health clinics, and family involvement and education for program adherence. This could be applied to firefighters by ensuring that they understand that they are at an increased risk for sudden cardiac death, educating them whenever possible during

10 PROTECTING THOSE WHO PROTECT US 10 clinic or in-patient hospital visits, performing appropriate comprehensive screenings, and performing follow-up calls to reinforce learning and create accountability. It is also the job of the community nurse to provide primary prevention in the form of education. As Kunadharaju et al. (2011) recommend, fitness and wellness programs are one of the most promising methods of prevention of sudden cardiac death (p. 1172). Community nurses could raise awareness of the risk of sudden cardiac death in the line of duty and begin programs that educate firefighters on proper nutrition, the effects of smoking, the importance of proper rest, and other habits of a healthy lifestyle. Nurses could also work with the heads of each fire department to develop an appropriate exercise program and teach classes to the firefighters on personalized exercise programs to improve the chance of adherence. They could also offer screening services to departments to identify firefighters at an increased risk for sudden cardiac death and assist them in developing a plan to incorporate healthier habits into their lifestyles. Summary Sudden cardiac death among firefighters is a real concern. It may be easy to overlook due to the fact that it concerns such a specific and seemingly narrow population, but it should not be ignored. The precautions in place are insufficient, and there are many steps that can be taken to decrease the risk of sudden cardiac death in the line of duty. The implementation of fitness and wellness programs, education programs on healthy lifestyle choices, raising awareness, screening programs, diagnostic physical fitness tests and exams, and teaching of early initiation of first-line treatment can all be performed by nurses to help reduce the risk of sudden cardiac death. It is the responsibility of nurses to provide education on these topics, and they can also provide screening and program management to further the impact of their involvement. The firefighters of the New River Valley provide a valuable and noble service to our community, and the nurses of our

11 PROTECTING THOSE WHO PROTECT US 11 community should take initiative in working toward promoting their health in order to allow each firefighter to fulfill their desire to help others instead of needing help themselves when a crisis arises.

12 PROTECTING THOSE WHO PROTECT US 12 References Allen, J.K. & Dennison, C.R. (2010). Randomized trials of nursing interventions for secondary prevention in patients with coronary artery disease and heart failure. Journal of Cardiovascular Nursing, 25(3), doi: /JCN.0b013e3181cc79be. (Last setion on page 212) Carpico, B. & Jenkins, P. (2011). Resuscitation review to improve nursing performance during cardiac arrest. Journal for Nurses in Staff Development, 27(1), doi: / NND.0b013e ca7 Coifman, K.G. & Bonanno, G.A. (2010). When distress does not become depression: Emotion context sensitivity and adjustment to bereavement. Journal of Abnormal Psychology, 119(3), doi: /a Kales, S.N., Soteriades, E.S., Christophi, C.A., & Christiani, D.C. (2007). Emergency duties and deaths from heart disease among firefighters in the United States. The New England Journal of Medicine, 356(12), Kunadharaju, K. Smith, T.D., & Dejoy, D.M. (2011). Line-of-duty deaths among U.S. firefighters: An analysis of fatality investigations. Accident Analysis and Prevention, 43(3), doi: /j.aap Lick, C.J., Aufderheide, T.P., Niskanen, R.A., Steinkamp, J.E., Davis, S.P., Nygaard, S.D., Bemenderfer, K.K., Gonzales, L., Kalla, J.A., Wald, S.K., Gillquist, D.L., Sayre, M.R., Oski Holm, S.Y., Oakes, D.A., Provo, T.A., Racht, E.M., Olsen, J.D., Yannopoulos, D., & Lurie, K.G. (2011). Take heart America: A comprehensive, community-wide, systems-based approach to the treatment of cardiac arrest. Critical Care Medicine, 39(1), doi: /CCM.0b013e3181fa7ce4

13 PROTECTING THOSE WHO PROTECT US 13 New River Valley Planning District Commission. 2010, December 7. Virginia's New River Valley regional data book. Retrieved 23 March, 2012 from New River Valley Planning District Commission: Poirier, P., Giles, T.D., Bray, G.A., Hong. Y., Stern, J.S., Pi-Sunyer, X., & Eckel, R.H. (2006). Obesity and cardiovascular disease: pathophysiology, evaluation, and effect of weight loss: An update of the 1997 American Heart Association scientific statement on obesity and heart disease from the obesity committee of the council on nutrition, physical activity, and metabolism. Circulation, 113(6), doi: / CIRCULATIONAHA Valencia, J. 2011, June 20. Volunteer firefighters getting harder to find. Retrieved on 24 March, 2012 from The Roanoke Times: Virginia Department of Fire Programs. 2012, March 12. Fire data and statistics. Retrieved 24 March, 2012 from Virginia Department of Fire Programs: fire_data_statistics/index.htm Virginia Department of Fire Programs. 2011, December 30. Frequently asked questions. Retrieved 25 March, 2012 from Virginia Department of Fire Programs: Virginia Department of Fire Programs. 2010, December 13. Line of duty death. Retrieved 24 March, 2012 from Virginia Department of Fire Programs: training/lodd.htm