Sudden Cardiac Death in Firefighters


  • Sudden cardiac death is the number one cause of line of duty death (LODD) for firefighters
  • Firefighting is stressful, physically demanding, and dangerous!
  • Many firefighters die during routine training or annual physical abilities testing
  • Fire departments should implement firefighter health, wellness, and fitness programs
  • FD-CPR should be incorporated into Rapid Intervention Team (RIT) training
  • A dedicated medical crew should be on standby for fire suppression or any strenuous training exercise
  • We must do more to minimize death and suffering associated with cardiovascular disease!

Statistics from the U.S. Fire Administration (USFA)

The USFA’s firefighter fatality incident database was searched from Jan 8, 2004 to Dec 25, 2013 (all available).

On duty firefighter fatalities

  • Total: 1047

Firefighter classifications

  • Volunteer: 53%
  • Career: 33.7%
  • Other (including wildland): 13.3%

Type of duty

  • On scene fire: 30.9%
  • Other on duty: 17.3%
  • After: 16.2%
  • Responding: 15%
  • Training: 10.5%
  • On scene non-fire: 7.6%
  • Returning: 2.6%

Type of incident

  • Structure fire: 29.3%
  • Not incident related: 28.5%
  • Wildland: 12.2%
  • Motor vehicle accident: 10.1%
  • Other: 5.9%
  • Emergency Medical Services: 3.5%
  • Weather/Disaster response: 1.4%
  • False alarm: 1.3%
  • Vehicle fire: 1.2%

Cause of fatal injury

  • Stress/Overexertion: 51.1%
  • Vehicle collision including aircraft: 17.2%
  • Caught or trapped: 9.8%
  • Struck by: 7.1%
  • Fall: 4.1%
  • Other: 3.8%
  • Collapse: 3.7%
  • Lost: 1.1%

Nature of fatal injury

  • Heart attack: 46.6%
  • Trauma: 27.1%
  • Asphyxiation: 7.4%
  • Burns: 5.5%
  • Other: 4.1%
  • Stroke: 3.8%
  • Crushed: 2.8%

Age of firefighter when fatal injury was sustained

  • Under 21: 3.9%
  • 21 to 25: 6.5%
  • 26 to 30: 5.6%
  • 31 to 40: 17.5%
  • 41 to 50: 25.4%
  • 51 to 60: 23.9%
  • 61 and over: 15.6%

CDC/NIOSH Fire Fighter Fatality Investigation and Prevention Program

The Fire Fighter Fatality Investigation and Prevention Program (FFFIPP) is administered by the National Institute for Occupational Safety and Health (NIOSH), part of the Center for Disease Control and Prevention (CDC). It performs independent investigations of firefighter fatalities in the United States.

The programs goals are:

  • To better define the characteristics of line of duty deaths among firefighters
  • To develop recommendations for the prevention of deaths and injuries
  • To disseminate prevention strategies to the fire service

If you haven’t been to the CDC/NIOSH website lately they have made some notable improvements. You can now easily search the database of firefighter fatality investigation reports — a process that used to be a bit cumbersome. You can sort the reports by state, incident year, type of medical, or type of trauma. You can also click on a particular state.

Searching firefighter fatality investigation reports (NIOSH reports)

NIOSH firefighter fatality investigation reports

2014 Cardiac Related Firefighter Fatalities in the United States

A search of the database indicates that NIOSH investigated 9 cardiac-related firefighter deaths in 2014. Of those, 5 occurred during training or physical abilities testing!

2014 firefighter cardiac related deaths mu

NFPA 1582: Standard on Comprehensive Occupational Medical Program for Fire Departments

To reduce the risk of sudden cardiac arrest or other incapacitating medical conditions among firefighters, the NFPA developed NFPA 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments. This voluntary industry standard provides the components of a pre-placement and annual medical evaluation and medical fitness for duty criteria that includes:

  • A medical history (including exposure history)
  • Physical examination
  • Blood tests
  • Urinalysis
  • Vision tests
  • Audiograms
  • Spirometry
  • Chest x-ray (as indicated)
  • ECG, cancer screening (as indicated), and
  • Immunizations and infectious disease screening (as indicated)

NFPA 1582 recommends an exercise stress test performed “as clinically indicated by history or symptoms” and refers the reader to Appendix A. 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
  • One or more risk factors for coronary artery disease (in men older than 45 or women older than 55)

Risk factors are defined as:

  • Hypercholesterolemia (total cholesterol greater than 240 milligrams per deciliters
  • Hypertension (diastolic blood pressure greater than 90 mm of mercury)
  • Smoking
  • Diabetes mellitus
  • Family history of premature CAD (heart attack or sudden cardiac death in a first-degree relative less than 60 years old)

American College of Cardiology (ACC) / American Heart Association (AHA)

The ACC/AHA guideline for exercise testing states the evidence is “less well established” (Class IIb) for:

  • 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:
    • Who are sedentary and plan to start vigorous exercise
    • Who are involved in occupations in which impairment might jeopardize public safety (e.g., fire fighters)
    • Who are at high risk for CAD due to other diseases (e.g., peripheral vascular disease and chronic renal failure)

IAFF/IAFC Fire Service Joint Labor/Management Wellness-Fitness Initiative

The IAFF/IAFC Fire Service Joint Labor/Management Wellness-Fitness Initiative recommends a sub-maximal exercise stress test without an electrocardiogram (although they do recommend a resting ECG as part of the annual physical).

Exercise Stress Testing of Firefighters

We know that exercise stress testing can be used to screen for coronary artery disease in many individuals. However, conducting exercise stress testing on asymptomatic individuals without known heart disease is controversial.

Having said that, I am 100% in favor of annual exercise stress testing for firefighters! I would not want the first sign of a flow limiting stenosis in my left anterior descending artery (LAD) to be sudden cardiac death during my annual fitness test, which is extremely strenuous (similar to the Firefighter Combat Challenge but with 2 trips up the stairs).

I give my department a lot of credit for offering annual exercise stress testing to our line firefighters. We use an organization called North Greenville Fitness (no conflict of interest) and they are a very professional organization.

mason likar lead placement

Tom Bouthillet on the exercise bike with Mason-Likar lead placement

I was particularly impressed by the accuracy of their precordial lead placement. This almost never happens!

greenville fitness 2

firefighter stress test

Comparison of the 12-lead ECG between baseline and peak exercise

greenville fitness 3

Britney and Natalie from North Greenville Fitness

When the unthinkable happens 

If a firefighter collapsed during training or on the fire ground would you be prepared?

      • Is it your policy to have a dedicated medical crew on standby?
      • Does your RIT team forward-stage an AED along with the rest of its rescue equipment?
      • Are you trained in Pit Crew CPR?
      • Would you know how to quickly undress a fully encapsulated firefighter wearing SCBA?
      • Will you work the cardiac arrest on scene until return of spontaneous circulation (ROSC)?

It’s a little bit different when it’s “one of our own.” If you don’t have a plan the situation is certain to be extremely chaotic. Unusual stress can have a negative impact on teamwork. Actions can be rash and mistakes can be made.

You owe it to yourself and your coworkers to check out Firefighter Down: CPR (FD-CPR) which was developed by my good friends Christopher Watford (@ecgwatford) and Michael Herbert (@bigGermanMike).

Statistically speaking this is the most likely cause of a line of duty death!


CDC – Fire Fighter Fatality Investigation and Prevention Program: Fire Fighter Fatality Investigation Report F2013-18. 2015. Available at: Accessed July 10, 2015.

Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher VF, Mark DB, McCallister BD, Mooss AN, O’Reilly MG, Winters WL Jr., Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Russell RO, Smith SC Jr. [2002]. ACC/AHA 2002 guideline update for exercise testing: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 106(14):1883–1892. Occupational Medicine. 2015. Available at: Accessed July 10, 2015.

International Association of Fire Chiefs (IAFC). A Fire Department’s Guide to Implementing NFPA 1582. 2015. Available at: Accessed July 10, 2015.

US Fire Administration: Firefighter fatalities in the United States. Appsusfafemagov. 2015. Available at: Accessed July 10, 2015.


About author

Tom Bouthillet
Tom Bouthillet - 25 posts

Tom Bouthillet (@tbouthillet) is Editor-in-Chief of (@ECGTraining) and Fire Captain/Paramedic in South Carolina where he is the Emergency Cardiac Care Program Manager and the STEMI and CARES Site Coordinator of his fire department.

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