Entanglement prop inside the survival house. (NIOSH photo)
On March 31, 2016, a 32-year-old male career fire fighter cadet (the Cadet) participated in SCBA (self-contained breathing apparatus) maze training inside a “survival house.” The training was the final day of a 3-day fireground survival program. He was wearing PPE (personal protective equipment) consisting of full turnout gear with SCBA (on-air). The Cadet was nearing the end of the course when he collapsed. A Mayday was called and the Cadet was removed from the building.
CPR (cardiopulmonary resuscitation) was begun. Ambulance paramedics who were at the facility for training provided advanced life support (cardiac monitoring, intravenous fluids and medications, and rescue airway). They also initiated active cooling measures because the Cadet’s core body temperature was 108.2°F (42.3°C). The Cadet was transported to the hospital’s emergency department (ED). Inside the ED, additional cooling measures were taken and advanced life support continued for 57 minutes. Resuscitation efforts were not successful and the Cadet was pronounced dead.
The autopsy report listed “hyperthermia and dehydration” as the cause of death and stated “the exact cause of the hyperthermia is unknown.” NIOSH investigators concluded that the physical exertion of the training performed in full PPE/SCBA contributed to the Cadet’s hyperthermia and exertional heat stroke.
NIOSH offers the following recommendations to help reduce the risk of heat stress-related injuries and fatalities among trainees and fire fighters at this and other fire departments across the country.
- Ensure that a comprehensive rehabilitation program is in place and operating, which follows recommendations in National Fire Protection Association (NFPA) 1584, Standard on the Rehabilitation Process for Members During Emergency Operations and Training Exercises.
- Strengthen the heat stress program by implementing (or reinforcing) the following recommendations for all training courses:
- Ensure that trainees are medically cleared by a physician knowledgeable about NFPA 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments, including the physical demands of fire fighter training and the PPE used.
- Educate/re-educate trainees on the importance of reporting off-duty injuries and medical conditions, to include use of medications or dietary supplements.
- Have onsite staff (e.g., paramedics) assess trainee risk for heat-related illness prior to strenuous training, to include any training in full turnout gear; consider use of a checklist or other screening tool.
- Ensure that trainees (and their instructors) are well-versed on NFPA 1584, to include recognizing early signs and symptoms of possible heat-related illness and understanding potential consequences if not promptly reported and treated.
- Ensure that onsite paramedics regularly monitor trainees for early signs and symptoms of heat-related illness (overall appearance, mental status, vitals, etc.) at a frequency based on training duration, intensity, and other relevant factors.
- Ensure that trainees remain well hydrated throughout all phases of physically demanding tasks.
- Ensure that trainees rehydrate during rehab to fully replace fluid losses from sweating. For multi-day exercises, encourage trainees to increase fluid intake during time away from training (off-duty hours, rest days) to reduce the risk of dehydration on subsequent training days [NIOSH 2015].
- Solicit input from trainees and instructors about removing barriers (real or perceived) to reporting or seeking medical attention for signs/symptoms of possible heat-related illness.
The following recommendations would not have prevented the Cadet’s death, but NIOSH investigators include them to address general safety and health issues:
- Ensure that training maze props or trailers used in SCBA confidence training have adequate safety features such as emergency egress panels, emergency lighting, ventilation, and a temperature monitoring system to measure the ambient temperature inside the maze.
- In addition to ice water immersion therapy, consider having a second rapid cooling method available that could be accessed quickly during strenuous training.
- Provide preplacement and annual medical evaluations for all fire fighters consistent with guidance in NFPA 1582.
- Provide fire fighters with medical clearance to wear SCBA as part of the fire department’s medical evaluation program.
- Perform an annual physical performance evaluation (physical ability test) for fire fighters.
- Phase in a mandatory comprehensive fitness and wellness program to benefit all firefighters.