Risky Business: Health Hazards On and Beyond the Fire Ground

Sara A. Jahnke, Ph.D.

Director & Principal Investigator

Center for Fire, Rescue & EMS Health Research National Development & Research Institutes

• Dad

• Grandpa

• William Jahnke, CEO, WHP

• Chief William Jahnke (Ret), Overland Park Fire Department

Start with Why…

Firefighting is Bad for Your Health

Firefighting: The Perfect Storm

Soteriades et al., 2013

For every cardiac LODD,

an estimated

17non-fatal cardiac events occur on duty

each year.

Firefighter Fatality Statistics

Soteriades et al., 2013

Causes of CVD

Meta-analysis

LeMasters et al.

(2006)

Cohort Study

Daniels et al. (2013)

Type of Cancer

SREa (95% CI)

Likelihood

SMRb (95% CI)

SIRc (95% CI) All

SIRc (95% CI) First

Bladder --

--

1.18 (1.05-1.33)

Brain 1.32 (1-12-1.54)

Possible

Buccal Cavity and Pharynx 1.23 (0.96-1.55)

Possible

1.40 (1.13-1.72)

1.39 (1.19-1.62)

1.41 (1.20-1.66)

Colon 1.21 (1.03-1.41)

Possible

Intestine 1.30 (1.16-1.44)

1.21 (1.09-1.33)

1.29 (1.16-1.43)

Kidney 1.29 (1.05-1.58)

1.27 (1.09-1.48)

1.24 (1.04-1.48)

Leukemia 1.14 (0.98-1.31)

Possible

Liver, Gall Bladder, Biliary 1.30 (1.06-1.57)

--

--

Lung 1.10 (1.04-1.17)

1.12 (1.04-1.21)

1.13 (1.04-1.22)

Meta-analysis

LeMasters et al.

(2006)

Cohort Study

Daniels et al. (2013)

Type of Cancer

SREa (95% CI)

Likelihood

SMRb (95% CI)

SIRc (95% CI) All

SIRc (95% CI) First

Malignant Melanoma 1.32 (1.10-1.57)

Possible

Melanoma

Mesothelioma 2.00 (1.03-3.49)

2.29 (1.60-3.19)

2.00 (1.31-2.93)

Multiple Myeloma 1.53 (1.21-1.94)

Probable

Non-Hodgkin Lymphoma 1.51 (1.31-1.73)

Probable

Oesophagus 1.39 (1.14-1.67)

1.62 (1.31-2.00)

1.71 (1.36-2.13)

Prostate 1.28 (1.15-1.43)

Probable

Rectum 1.29 (1.10-1.51)

Possible

1.45 (1.16-1.78)

--

--

Skin 1.39 (1.10-1.73)

Possible

Stomach 1.22 (1.04-1.44)

Possible

Testis 2.02 (1.30-3.13)

Possible

The Data: Cancers Related to Firefighting

“Toxic Soup” of Known & Unknown Carcinogens

• CO

• Formaldehyde

• Metals

• Flame retardant (PCBEs)

• Benzene

• PAHs

• NO2

• Glutaraldehyde

• Toulene

• Zylenes

• Styrene

Note: Short duration but high intensity believed to be

particularly dangerous

Exposures

Routes of Exposure: Secondary Exposure

Cancer

Exposures Diet

Genetics

TobaccoAge

Alcohol

Hormones

Obesity

RadiationExcessive

Sunlight

Exercise

Infectious

Agents

Obesity• Fitness

• Nutrition

Alcohol Use

Tobacco Use

Sleep

Exposures

Modifiable Risk Factors

Document Review• Medical records

• Depositions – department

liabilities (e.g. physicals,

mitigation, culture)

• SOGs/SOPs

• Exposure records

Cancer Link: Making the Case

Type of Cancer Increased Risk Type of Cancer Increased Risk

Esophageal 2x Meningioma (Brain) 50%

Gastric Cardia 2x Colorectal 30%

Liver 2x Pancreatic 1.5x

Kidney 2x Gallbladder 60%

Multiple Myeloma 10-20% Thyroid 10%

National Cancer Institutehttps://www.cancer.gov/about-cancer/causes-prevention/risk/obesity/obesity-fact-sheet

Obesity and Cancer

Chronic low-level inflammation

Fat Cells Produce Adipokines

(e.g. Leptin)

Insulin Resistance

National Cancer Institutehttps://www.cancer.gov/about-cancer/causes-prevention/risk/obesity/obesity-fact-sheet

DNA Damage

Stimulate/Inhibit

Cell Growth

??

Obesity: Proposed Mechanisms

BMI (kg/m2)

• Overweight = BMI>25 and <30

• Class I = BMI>30 and <35

• Class II = BMI>35 and <40

• Class III = BMI>40

Body Fat Percentage

• Men, BF%>25

• Women, BF%>30

Waist Circumference

• Men WC>40 inches

• Women WC>35 inches

Definition of Obesity

79.5 78.4

33.5

43.2

30.5

45.247.7

54.3

0

10

20

30

40

50

60

70

80

90

100

Career Volunteer

Pre

vale

nc

e (%

)

Overweight+Obesity (BMI>=25)

Obesity (BMI>=30)

Obese (WC>40 for men)

Obese (BF%>25 for men)

US Overweight

Prevalence=68.0%*

US Obesity

Prevalence=33.8%*

*Flegal et al. JAMA 2010;303:235-241

Firefighter Data from Poston et al., 2011: FIRE Study. Range in the published literature, BMI > 25: 73-88%

Overweight and Obesity Prevalence

Fire & Emergency Services

Nutrition Environment in the fire house• Irregular eating patterns an unpredictable schedules• Portion size, meal planning, and traditions• Processed carbohydrates and sugar

Metabolic impact of shift work

Lack of support for physical activity in some departments

Time constraints for healthy behaviors

Behavioral health concerns

Reasons for the Obesity Epidemic

Food in the Firehouse

“…just eating with them on those days I put on some

weight and it’s very difficult to do that because part of

the fire service family is built around that kitchen table.

That’s where it takes place. That’s where real problems

are solved.”

“Yeah, at some stations, just everybody just brings their

own food in…You know, they have problems in their

groups and they don’t seem to cook up as much…just

like guys that don’t get along together.”

Meals as Bonding

Firehouse Environment

• Irregular eating patterns

• Traditions

• Food availability

Portion Sizes

#1

#2

#3

#4

#5

#6

https://www.firerescue1.com/fire-chief/articles/204588018-Study-shows-where-firefighters-get-calories-its-not-pretty/

Top 6 Sources of Calories

Focus on diet quality

Avoid or limit processed food

Limit sugar intake

Stay hydrated

Fruits and vegetables are good

Eat healthy fats

Take care of your gut health

Evidence Based Dietary Advice

People who plan to eata health, low-cal meal

People who wishthis was REALLY pie

• Head & Neck: 50+ grams of alcohol/day (~3.5 drinks) have 2-3x risk

• Breast: women who drank 45+ grams of alcohol/day (~3 drinks) have 50%

higher risk

• Colorectal: 50+ grams of alcohol/day (~3.5 drinks) have 50% higher risk

• Liver: primary cause particularly hepatocellular carcinoma

• Esophageal: independent risk factor particularly for esophageal squamous

cell carcinoma

National Cancer Institutehttps://www.cancer.gov/about-cancer/causes-prevention/risk/alcohol/alcohol-fact-sheet

Alcohol & Cancer

Metabolizing Ethanol: Acetaldehyde

Impaired Absorption of Nutrients

Fermentation

National Cancer Institutehttps://www.cancer.gov/about-cancer/causes-prevention/risk/alcohol/alcohol-fact-sheet

Damage to

DNA & Proteins

Malnutrition

Damaging Chemicals(nitrosamines, asbestos, hydrocarbons)

Alcohol: Proposed Mechanisms

U.S. Center for Disease Control & Prevention

Definitions: According to Scientists

1 drink =

U.S. Center for Disease Control & Prevention

Definitions: According to Scientists

Heavy Drinking

• 53% career

• 39% volunteers

Binge Drinking

• 56% career

• 45% volunteers

About 10% of firefighters reported driving

while intoxicated in the past month

Alcohol Use by Firefighters in Central US

Survey (All participants)

Heavy Drinking: 44.7%

Binge Drinking: 50.2%

Average daily intake: 3.5 drinks

Dietary Recall (Off duty days)

Beer Drinks: 3.9

Wine Drinks: 2.0

Liquor Drinks: 6.8

Calories from alcohol:

Average = 551.4 kcals

Range = 12.5 to 3,404

Alcohol Use and Abuse

National Cohort of US Career Firefighters

Calories from Alcohol

Calories from Alcohol

25% Drank the Caloric Equivalent of 3 Snickers Bars (> 774 calories)

Shift Schedule: “One thing that's different with us, though, I mean we work ten days a month, so we got a lot of days that we don't work the next morning. That's one reason why - maybe that's my excuse, I don't know.” Firefighter, Career

Camaraderie: “I use it as an excuse to unwind on the four days, you know what I mean? You get together in a big group, go out, have a drink, tell war stories, laugh about stuff we did. Just act - act like exactly we did at the station, except do it with beer - with a drink.” Firefighter, Career

Stress Management: “The stress of the job…when you get off…you want something that will help you unwind.” Firefighter, Career

Tradition: “They (firefighters) all seem to be social and if you look back throughout the history of the fire service when my great grandfather was on up through the ranks what's union hall if there wasn't an open bar or a party somewhere.” Chief, Career

Alcohol Use: Reasons

Can you outrun your dessert?

1 Pint – 1,360 caloriesRunning (5mph)

2 Hours, 5 Minutes

Race Walking

2 Hours, 30 Minutes

Walking-a-Dog Pace

5 Hours, 33 Minutes

Can you outrun your dessert?

119.5 grams 442.1 grams12.8 grams

Sugar Intake

Sisson (2009) The Primal Blueprint

Average Intake:

290.9 g Carb/day

Minimum:

90.8 g Carb/day

Carb Intake

Max: 834.2 g carb/day

5 mph

5 hours 6 min

25.5 Miles

A MARATHON

Carb Intake

800

“Exercise is what gets you hurt”

Training33%

Fireground27%

Non-fire Call17%

Responding/Returning

8%

Roadway1%

Other on Duty14%

Data from Jahnke et al. 2013Distribution similar to findings of Poplin et al. , 2012

Line of Duty Injuries by Job TaskLine of Duty Injuries by Job Task

Exercise Injuries

• Develop resources in the department

• Warm ups

• Encourage scaling

• Discuss importance of proper form

• Functional exercises

• Time limitations

• Hydration

• Intensity

• Equipment availability

Best Practices: Fitness

“Tobacco is the leading cause

of cancer and death from cancer.”~ National Cancer Institute

https://www.cancer.gov/about-cancer/causes-prevention/risk/tobacco

Tobacco & Cancer

“There is no safe level

of tobacco use.”~ National Cancer Institute

https://www.cancer.gov/about-cancer/causes-prevention/risk/tobacco

Tobacco & Cancer

Lung

Larnyx

Mouth

Esophagus

Throat

Mouth

Esophagus

Pancreas

Tobacco & Cancer

Bladder

Kidney

Liver

Stomach

Pancreas

Colon

Rectum

Cervix

Acute Myeloid

Leukemia

Unadjusted Rates of Current Smoking

13.6% for Career Firefighters

17.4% for Volunteer Firefighters

Cigarette Use Among Firefighters

0%

5%

10%

15%

20%

25%

Career Age

Standardized

Career

Volunteer US Males

Pe

rce

nt

SLT Users Were:• Younger

• Had fewer years in the Fire & Emergency Services

• A small percent (15.7%) used because of departmental restrictions on

smoking

Rates of Smokeless Tobacco Use

May be due to interruption of circadian

rhythms

Suppression of melatonin at night

Sleep apnea related to increases in

several types of cancer*

*Christiansen et al., 2013

Sleep, Shift Work & Cancer

Sleep Disorders (37%) *Linked to:

• depression,

• CVD,

• crashes,

• diabetes,

• anxiety,

• obesity

48+ Hour Schedules

Linking Shifts

Busy Houses

Private Quarters

Sleep Promoting Environments

Napping

Effective use of caffeine*Barger et al. 2015

Sleep Management

“Your worst day is our everyday”

~Into the Fire (2005)

www.ironfiremen.com

Acute Exposures (e.g. LODD,

terrorist attack)

Chronic Repeated Exposure to Trauma

Environmental Exposures

Sleep/Circadian Rhythm Disruption

Injury/Disability

Depression

Anxiety

PTSD

Cardiovascular Disease

Substance Use/Abuse

Home/Life Stressors

Cancer

Suicidal Ideation

Epigenetic Changes

Resilience & Post Traumatic Growth

A Complex Interplay

Heroes vs. Heroic

•PTSD• Wide range but as high as 13-22%• 3.5% in general population

•Depression• 12-27% in the range of concern in fire service samples• Typically <10% in general population

Depression & PTSD

•Recent survey, nearly half of firefighters report having considered suicide

•15.5% reported attempting suicide

•Women in protective services (fire, law enforcement, EMS) had the highest rate of suicide of any occupation studied

•1.9-8.7% in general population attempt suicide

Suicide

•7,000 firefighters responded•27 percent have struggled with

substance abuse•59 percent have experienced

family and relationship problems•65 percent are haunted by

memories of bad calls•19 percent have had thoughts of

suicide

Current Headlines

VS

Behavioral Health Paradigms

Incident Evaluate Intervene Recover

Behavioral Health as a Heart Attack

•Different incidents effect people differently

• Intervention is not the same for all

• Impact not always immediate

• Iatrogenic responses

Challenges to the Existing Paradigm

• Long term problem, long term solution

• Shift in lifestyle/culture

• Awareness

• Monitor symptoms

• Treat as appropriate

• Appropriate level of intervention

New Paradigm Approach

• Increased awareness of complex relationships

• Department level awareness and support

• Peer support programs as a resource

• Empower peer team creativity

• Warm hand offs when necessary

Opportunities

What is working so well in the fire service?

•Camaraderie

•Dark humor

•Social support

•Debriefing

• Family support

•Sharing experiences

• Fire service identity

• Buy in from all directions

• Building a peer team

• Identifying resources

• Regular interaction of team

• Team self-care/vicarious trauma

• Prospective hindsight

• Ongoing evaluation

• Training

• Peer team

• Awareness

Creating a Behavioral Health Program

So what is the good news?

Health Outcome Wellness Department Standard Department p-value

Obesity Status (%)

-BMI 25.3% 35.6% 0.002

-BF% 33.3% 43.5% <0.001

-WC 23.0% 32.8% <0.001

Measured HTN 16.2% 23.7% 0.001

Meets NFPA Recommended METs

(% yes)

46.8 43.0 <0.001

Estimated VO2max 40.7±0.6 37.5±1.3 0.001

Exercises at Station

(% Most-Every Day) 72.9% 40.6% <0.001

Poston et al. (2014): F2F

Firefighter Wellness Programs Work!

Implement department wellness programs

• Fitness, nutrition, sleep hygiene, mental health

Regular, relevant, physical ability testing

Promote a tobacco-free workplace

Require pre-employment medical evaluations

Require annual medical evaluations

Provide education and resources for behavioral health

Action Steps for Fire Departments

Maintain a high level of physical fitness

• Fitness – across domains, function

Maintain/take actions to reach a healthy weight

• Nutrition – processed foods, sugars, alcohol, hydration

Avoid excessive use of alcohol

Eliminate tobacco use

Get adequate sleep

Obtain an annual physical

Action Steps for Firefighters

• Colon cancer: 91% 5 year survival if caught early, 11% if it has already spread (Horner et al., 2009)

• Prostate cancer: 100% 5 year survival if caught early (ACS, 2009)

• Breast cancer: 98% 5 year survival if caught early, 15% survival in later stages (ACS, 2009; Cancer Research UK)

• Bowel cancer: 9 of 10 will survive 5 years if caught early (Cancer Research UK)

Ref: Surveillance, Epidemiology, and End Results Program (SEER), 1973-2006. Division of Cancer Control and Population Sciences, NCI. Bethesda, MD. 2006.

Cancer: Early Detection is Key

Take Control of Your Own Health

Exposure Research: What’s on the Horizon

• 1,500 organic

• Cohort study, matched air samples, blood urine

• 2 Departments• High Volume/Low Volume

• On Duty/Off Duty

Exposure Research: What’s on the Horizon

Exposure Research: What’s on the Horizon

How Clean is Clean?

(1) Clean and soiled outer shell fabric swatches side by side with electron microscope photographs showing dirt particles embedded in the soiled swatch under extreme magnification. (Photo courtesy of the NIOSH National Personal Protective Technology Laboratory and Health Effects Laboratory Division.)

Questions?

Risks beyond the Fire Ground Fitness, Nutrition, Substance Use & Sleep

Dr. Sara JahnkeCenter for Fire, Rescue & EMS Health Research

sara@hopehri.com

913-238-5648