Is your fire service prepared? Firefighter cardiac arrest – Part 1
As all of us know, firefighting is a dangerous profession and it is increasingly evident that firefighters are at a much higher cardiovascular risk than any other profession; this is due to a range of different exposures and workloads created by our profession.
Fighting fires is continually being described by researchers as physiologically high-risk, and that firefighters should be treated more as industrial athletes then the traditional firefighter.
Although understanding prevention through education, good health, exercise, affective standard operating procedures, and personal protective equipment is best practice.
Understanding this and looking at the reality of the job, specifically the time and resources that are needed before fire departments to produce and maintain a healthy workforce. I asked myself how we can prepare for the worst, if a firefighter collapses and goes into cardiac arrest within the fire building. This is a question I, and many other crews have asked themselves, as preparing for the worst allows for an effective and timely response to any situation.
This article outlines the physiological and toxicological effects the firefighting environment has on the human body, and how they can contribute to the risk of firefighter cardiac arrest. What happens to the physiology of the body once an arrest has occurred, and the implications and limitations of responding in the firefighting environment will be discussed. The benefits of high-quality Cardiopulmonary Resuscitation (CPR) the efficiencies gained by using a rehearsed drill and the appearance of promising results within drills used with in other fire departments. This article will then go on to outline how CPR can be adapted to create an effective drill in a firefighter down scenario (wearing full turn out ensemble and SCBA. The advantages of implementing a firefighter down cardiac arrest drill in fire department training, such as the firefighter down cardiac arrest drill (FDCAD) will also be discussed.
The physiological effects of the fire ground cause significant stress to be placed on the heart. The elevated temperatures, exposure to toxic substances and high physical strain, cause an increased workload, weakness, oxygen deprivation and pressure on the cardiac muscle. This results in a reasonably fit firefighter being placed in a high risk category. Other risk factors that dramatically increase the risk of cardiac arrest among firefighters are increased age, smoking status, poor physical fitness, high body mass index and cardiac history.
When taking into account the high levels of physical and cardiopulmonary fitness needed to conduct firefighting operations, the largely ageing demographic of the workforce and the physiological impact the fire ground environment takes upon firefighters. It is not surprising that sudden cardiac arrests are the number one killer of firefighters and an ever present risk.
In a study conducted in Amsterdam of 873 people who suffered cardiac arrest it reported when bystander CPR was performed it resulted in a survival percentage of (14%). Compared with a survival percentage of (6%) when no bystander CPR was carried out before arrival of paramedics
Taking these figures into account and understanding the CPR survivability scale in which a 7% to 10% chance of survival is lost every minute without CPR, and an average rescue time of a down firefighter taking between 7.5 to 21 minutes. This shows that in the best case a firefighter has a 25% chance of survival on removal from the fire building, if efficient and effective CPR practices are initiated immediately on their removal.
“How do we deliver the very best, time efficient, medical response to a down firefighter”? With this question of in mind I embarked on a validation study supported by Charles Sturt University, and my department Fire and Rescue New South Wales. This assessed the effectiveness of a firefighter CPR drill that has emerged in recent times, initially developed by the firefighters of Leland Fire Department North Carolina. The drill was dubbed Fire department cardiopulmonary resuscitation (FDCPR) or for our purposes Firefighter down cardiac arrest drills (FDCAD) in which the method was changed a small amount to aline better with the Australian resuscitation council guide lines.
This method appeared to facilitate early CPR for a down firefighter as well as rapid removal of bunker gear and SCBA while conducting an efficient well practised CPR drill. This was to be compared against the standard New South Wales Fire and rescue drill, which was for rescuing firefighters to swarm the casualty on removal from the fire building and remove the casualty from all equipment in an un-orchestrated manner, and then begins CPR.
The validation study (Beta test) focused on several key outcomes to gain a better understanding of the drills efficiencies and downfalls. The goals of Beta testing included establishing a baseline of user performance, establishing and validating user performance measures, and identifying potential design concerns to be addressed in order to improve the efficiency, productivity, trainability and end-user satisfaction. The Beta test objectives included determining design inconsistencies and usability problem areas within the Firefighter CPR drill.
- Training errors – failure to educate personnel giving them an understanding of the drills functions, requirements and uses.
- Timing errors – failure to properly carry out the drill within an appropriate timeline consistent with the pathophysiology of cardiac arrest.
- Cardiac arrest identification-the ability for responding firefighters to identify whether or not the casualties is in cardiac arrest and how to respond.
- Efficiency problems – failure to achieve CPR drill efficiency from a physiological standpoint including rate, quality and depth of compression.
- Fatigue error- failure of rescuer to maintain efficient CPR due to fatigue created by drill design.
- Encoding/ confidence error- failure of personnel to confidently recall and perform drill post education.
- And finally other equipment-identify potential problems that equipment carried by firefighters at a fire scene may present to the drill such as radios, webbing, truckies belts and so on.
At the beginning of the study participants were asked to attend a three hour CPR training course prior to the testing day outlining basic CPR, standard Firefighter down procedures, and the FDCPR /FDCAD procedure being assessed. Prior to the beginning of the session the participants were required to fill out a confidence and encoding survey to assess the current knowledge and confidence with CPR, and the Department firefighter down procedure. The beta study comprised of 4 voluntary participants per session, drawn from the ranks of Fire and rescue New South Wales, with testing being conducted at the Charles Sturt University’s Bathurst City campus Paramedic training simulation space.
Measurements pertaining to CPR efficiency were obtained via accelerometer built-in to a CPR manikin measuring CPR efficiency such as time of first intervention, rate, rhythm, quality, G-Force exerted on patients and ventilation volume. This information was then downloaded onto computer the further analysis.
Secondary to this, participants in scenarios were also video recorded and time stamped, on completion of set interventions such as removal from SCBA. These were predominantly used to assess the speed of disrobing the injured firefighter, due to flexibility issues with the manikin and a live participant having to take its place.
When assessing the ability to confirm arrest decibel readings were gathered to identify the sounds of breathing on a casualty withholding breathing, at rest, and fatigue this allowed the study to identify if it was reasonable to assess a patient through and SCBA.
Additionally to this a watch and feel test was completed with patients in personal protective equipment displaying no, shallow, and deep respirations with rescuing firefighters tempting distinguishing between them.
Measurements were also gathered by biometric shirt (hexoskin’s) and automatic blood pressure cuff’s, which record and observed vital signs, fatigue, and external G-Force of rescuers. This allowed us to assess the level of exertion rescuing firefighter sustain throughout the evolutions and the timeframe they could efficiently maintain rescue efforts while wearing their own personal protective equipment.
The test space comprised of an active test box marked in red, and two start marks also marked in red.
This allowed a realistic view and timeframe for the rescuing firefighter to remove the patient from the fire building and other rescuing firefighters to converge on them to begin the resuscitation.
At the commencement of testing, a Baseline test was conducted measuring Firefighter performance conducting a regular CPR procedure on a manikin with a one hour rest between tests. Four tests were then conducted measuring the new procedure and standard fire rescue techniques with a manikin and live patient with a one hour rest time between tests. Finally on conclusion of testing participants were given the confidence and encoding questionnaire once more, assessing their perception of the newly learned material.
On completion of the testing and collation of the data Beta testing preliminary findings have shown significant differences in relation to the three types of CPR drills tested.
The results of this study will be reviewed and further discussed in part two of this article.
For more information, go to www.fire.nsw.gov.au