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Heart disease is any disease that affects the heart or blood vessels

E.g., Cardiovascular disease (CVD), heart failure, cardiomyopathy

Firefighters experience the highest mortality due to CVD on-duty than any other occupation ^[1]

CVD accounts for 45% of on-duty deaths per year ^[1]
For every fatal cardiac event there are an estimated 17 non-fatal cardiac events ^[1]

Heart disease and Firefighting

This Photo by Unknown Author is licensed under CC BY

Heart disease (HD) is the leading cause of death and disability worldwide and includes any disease that affects the heart or blood vessels. Including cardiovascular disease, heart failure, cardiomyopathy, and acute cardiac events like heart attack and stroke. Heart disease affects a tremendous amount of the global population, and even more troubling, literature has shown that firefighters experience the highest rates of cardiac-related mortality compared to any other occupational group (Soteriades et al., 2011). CVD accounts for 45% of on-duty deaths per year, and there are an estimated 17 nonfatal cardiovascular events for every fatal on-duty HD event among line-of-duty FFs (Soteriades et al., 2011). In response to these troubling statistics, a series of studies looking at heart disease among firefighters was designed and completed as my PhD dissertation. Today I will be discussing one of these studies, which looked at the experience of firefighters who had an acute cardiac event during their career as a firefighter.

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Acute Cardiac Events and Firefighting

Acute Cardiac Event ^[2,3]

A sudden event that impedes blood flow and/or the heart to function
Immediate medical intervention is required ^[2,3]

Include heart attack, cardiac arrest, stroke/aneurysm rupture, unstable or new onset angina ^[2,3]
Firefighters are hypothesized to have a higher risk of acute cardiac events due to high mental and physical occupational demands ^[3]

This Photo by Unknown Author is licensed under CC BY

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Occupational Stressors and Heart Disease among Firefighters

Based on references [5-10]

Most of you have probably heard the saying at some point “stress kills”. A rather extreme sentiment but conveys the point that stress contributes to many negative physical and mental health outcomes. On this slide I will break down the hypothetical way in which stress may turn into heart disease and acute cardiac events as supported by scientific literature.

Within the available scientific evidence, it is suggested that occupational stress, both mental and physical, experienced among firefighters increases the risk for heart disease and acute cardiac events. Specifically, we believe that occupational stressors may manifest into heart disease through repeated or chronic activation of the stress response system and after a firefighter develops heart disease, they become increasingly vulnerable to acute cardiac events, particularly during strenuous activity or high stress events (Angleman et al., 2022; Soteriades et al., 2011; Stretton & MacDermid, 2024).

This mechanism is rooted in occupational stressors. FFs’ stress response system is activated each time there is an emergency dispatch. This repeated activation of the stress response becomes a chronic activation, which may then manifest into HD. Additionally, the transition from rest to peak performance and strenuous activity experienced during emergency dispatches may trigger an acute cardiac event in people with an underlying heart condition. �

The second part of this mechanism is focused on CI exposure and occupational stress injuries. Where a CI can be commonly described as sudden and overwhelming traumatic events that "exceed beyond an individual's normal coping skills, common exposures include incidents with multiple casualties, self-inflicted trauma, and serious injury or death to children.

There are several ways in which exposure to workplace CIs may make a FF more susceptible to HD or an on-duty cardiac events: (1) repeated exposure to CI’s resulting in repeated activation of the stress response system, (2) development of an occupational stress injury resulting in chronic activation of the stress response system, which is also linked to increased sleep disturbances and adverse coping that may compound the risk for the development of heart disease and (3) CI exposure in someone with an underlying heart condition may result in an acute cardiac event (e.g., heart attack).

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Stress and heart disease are highly related ^[4-6,11]
Occupational demands from firefighting put excess strain on the heart ^[4-6,11]

Increases risk for acute cardiac events ^[4-6,11]

Missing/unknown:

Discourse on the treatment and recovery process for firefighters
How to successfully return to a high-stress work environment

What Do We Know from Current Scientific Evidence?

It is clear from the general literature that stress and heart disease are highly related. Within fire-specific literature, we know that high-stress occupational demands like critical incident exposure, rest-to-peak performance, and shiftwork put excess strain on the heart and increase the risk for acute cardiac events, especially among people with underlying heart conditions.

However, absent from this literature is discourse on the treatment and recovery process for firefighters, including how to successfully return to this high-stress work environment. In general, there is limited literature on the RTW process for general injuries among firefighters, and to our knowledge, there is none on returning after a cardiac event. This missing discussions within scientific literature is what drove this study as we aimed to fill these gaps.

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Research Questions

What are the experiences in the treatment, recovery, and RTW process among firefighters who have had an acute cardiac event during their career?

Goals

Explore the experience of treatment, recovery, and RTW
Identify treatment targets to better support firefighters during their treatment, recovery, and RTW
Add to the gap in the literature

How we did this

Interviewed firefighters who had an acute cardiac event, exploring their treatment, recovery, and RTW

Research Question(s), Type of Study, and Goals

The research question for this study was what are the experiences in the treatment, recovery, and RTW process among firefighters who have had an acute cardiac event during their career? Participants were eligible to participate if they had had an on or off-duty acute cardiac event (i.e., heart attack/myocardial infarction, cardiac arrest, stroke/aneurysm rupture, and unstable or new onset angina) during their career as a firefighter. There were no restrictions on the type of firefighting, career type (i.e., career, volunteer, paid-on-call), or country of work.

The occupational demands of a firefighter are inherently psychologically and physically stressful. The stressful demands of the occupation are inevitable; however, they can be mitigated with the proper supports and tools. As such, this study aimed to gain a better understanding of the treatment, recovery, and RTW process for acute cardiac events among firefighters, with a specific focus on the stress and mental health component of recovery, treatment, and RTW. The results of this study aim to identify future treatment targets to better support firefighters during their treatment, recovery, and RTW following an acute cardiac event and add to gaps in the current body of literature surrounding RTW among firefighters.

To complete this study, we invited eligible firefighters to complete an online interview where they were asked about their treatment, recovery, and RTW process with a specific focus on mental health implications and experiences. We then analyzed and compiled firefighters common experiences to meet the goals of our study.

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8 participants
5 Canadian and 3 US firefighters
All identified as male
35 to 65 years old
Most cardiac events occurred in their 40’s
Events typically occurred within 24-hours of their last shift or on duty
Most participants had no symptoms leading up to their event (n=6) and no diagnosis of heart conditions (n=5)

Sample

The participants included eight firefighters who experienced a heart attack, cardiac arrest, or unstable angina, where a heart attack was the most common experince.

There were five participants from Canada (Ontario n=3, British Columbia n=1, Newfoundland n=1) and three from the United States (Maryland n=1, North Carolina n=1, undisclosed n=1). All participants were male, and the age they experienced their cardiac event ranged from thirty-five to sixty-five years old.

Most participants (n=5) were in their forties when they experienced their cardiac event. Cardiac events most often occurred within twenty-four hours of their last shift or while on duty, and at the time of their event, most participants were actively engaging in strenuous activity or had just finished engaging in strenuous activity. Notably, most participants had no symptoms leading up to their event (n=6) and no diagnosis of heart disease or heart conditions (e.g., high blood pressure, high cholesterol, coronary artery disease) prior to their event (n=5).

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Results: Treatment and Recovery Process Major Themes

[The fire department and doctors] didn’t offer any mental health resources; it wasn't even considered. But I [also] never asked for any. So, I guess I hold as much responsibility as the city or job for not utilizing those assets.

If I hadn't been so proactive and demanding, I think I would have slipped under the carpet. I truly believe that, and I'm not mad at anybody…I just know that if I hadn't initiated this, it wouldn't [have] happened.

Just being able to talk about it [is so important]. If I weren't able to do that, I don't think I would have ever recovered because I would have been so scared living in a box that I didn't want to come out of because I was worried that something was going to happen [again].

It parallels the medical side of things because if your mind's not healthy, your body suffers.

I don't know if I could have gone through the [cardiac rehab program] without [the mental health component] now.

[There is a] stigma having a job that requires physical activity... So, it's a personal choice to keep [my heart issues] hidden.

Your arm could be falling off, and someone will ask you ‘how are you’ and you'll say you're fine, there's nothing wrong. You never bring attention to yourself. You're never sick, you're never hurt.

My cardiologist wasn't following a prescribed RTW plan for a firefighter but was following a RTW for [the general public] .... [There was no] can you climb these stairs? Can you do the stress test on the Treadmill? I wasn't being put in any kind of scenario that would test my physical or mental skills to say that you're fit [and ready to RTW] or no, we think you need more time off, and you need to spend a couple of weeks in training to get yourself back into game shape.

On this slide we will summarize the major themes around treatment and recovery.

Despite having participants from different geographical locations, most participant` had similar healthcare experiences. Most commonly, five of eight participants reported that there was a lack of consideration of what it means to be a firefighter in the diagnosis, treatment, and recovery process. Participants believed that firefighters are a unique population due to lifestyle and occupational demands, which need to be considered during diagnosis, treatment, recovery, and RTW. One-half of the participants suggested that firefighters need a specific treatment and RTW plan tailored to their lifestyle and occupational demands to ensure a successful RTW.

Moreover, during initial diagnosis, two participants discussed that they believed there was a medical bias towards firefighters as they are perceived as “inherently healthy” due to their physical occupational demands. Participants believed that when doctors viewed them as “inherently healthy,” they neglected to consider various hazardous components of the job that cumulate over time and impact one’s health, including shift schedules, lack of sleep, rest-to-peak performance, adrenaline surges, and mental health difficulties. As a result, these two participants did not feel completely confident with the medical choices made by their doctors, as they did not feel the doctors understood what it means to be a firefighter.

One participant commented:

During treatment, recovery, and RTW, there was no inclusion of a mental health/wellness component for most participants. Six participants said there was no discussion or consideration of a mental health component, one participant said they were recommended to a mental health professional after “having an emotional breakdown” during a treatment session, and the remaining participant did not comment. Two participants remarked on their experience:

Despite the lack of consideration of mental health/wellness during treatment and recovery, all participants reported adverse mental health outcomes following their acute cardiac event. All participants discussed feelings of anxiety following their event, and half spontaneously said that the mental health component was the most difficult part of recovery. Common anxieties included: questioning physical and mental abilities - which was discussed in relation to needing a fire-specific treatment and RTW plan to build confidence before returning to work; difficulty overthinking; fearing re-injury; and fear of job loss and connection with the FD.

Regardless of all participants experiencing adverse mental health outcomes following their event, only half received mental health support. All participants who received mental health support engaged in talk therapy as their primary form of support. All except one sought this support themselves. Three participants commented on their mental health experience during treatment and recovery:

Lastly, we explored the fire culture impact on treatment and recovery. This included discussions about social factors and beliefs within the fire service and within their station specifically. When participants were probed about social and cultural factors within the fire service that influenced their recovery and RTW, six of eight participants spontaneously discussed stigma within the fire department. Participants reflected that stigma around mental health difficulties within the service deters firefighters from seeking and accessing mental health support.

Additionally, half of the participants indicated that there is a physical illness stigma within the fire service that is less often talked about compared to mental health stigma. They believed that physical illness stigma negatively affects the recovery and RTW process by encouraging firefighters to hide their illness, dismiss and ignore symptoms, push themselves, and ultimately RTW prematurely. All participants who reported dismissing and ignoring symptoms and pushing themselves (n=5) before and or after their event believed there is mental and or physical illness stigma within the service.

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Results: The RTW Process Major Themes

1 Year

RTW Timeline

6-months

3-months

On this slide we will go through major themes surrounding the RTW process. Participants were asked to discuss their RTW process in as much detail as they wished, including timeline from injury to RTW, duties upon return, positive and negative factors in their return, and recommendations for an ideal RTW process.

Before we go into the themes I will briefly discuss RTW timelines and duties among our participants. The timeline of injury to RTW varied considerably among participants, spanning from no time off to a year; no participants shared the same return timeline. As you can see on the slide here most participants returned within 3 months of their injury, where two returned with no time off. During discussion of RTW timelines, half of the participants spontaneously reinforced the idea that RTW is individual-specific and that set timelines do not work and contribute to stress in the recovery and RTW process.

Similarly to RTW timelines, participants varied considerably in duties upon their return. Five participants returned to normal duties, two participants returned with modified duties, and one participant returned but with an indefinite removal from suppression and strenuous tasks.

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Results: The RTW Process Major Themes

Having that ability to connect … is a big part of your recovery process, and if your employers are bad at it, I think that's where you fall.

You immediately go into light duty to protect your sick bank, and the irony is that we say we've got to protect our sick bank in case something bad happens, you just died, and you're thinking something worse is going to happen. So, three weeks later, I'm back working 40 hours a week... I should have been offline for a year… and working on the mental piece more than anything, but that's not how the profession works.

I was off work for five months. My employer contacted me twice in that period. I had lots of connections to other members of the department, but my employer only wanted to fill out the work safe forms and know when I was coming back, nothing in between...I was just set adrift… There were no phone calls, no ‘how are you?’ ‘How's life?’ ‘See you later.’ ‘Screw off.’ Anything. There was nothing, just no connection.

The RTW process has been split into positive factors, negative factors, and recommendations.

Positive factors that were identified in the RTW process were almost exclusively social support from different sources: family, friends, and peers (n=5); the department (n=4); and the union (n=2). All participants except one spontaneously said that social support was a major component to ensure a successful RTW.

The only other common subtheme identified in positive RTW components was the ability to work with the same crew. Five of eight participants reflected that the camaraderie, comfort, and routine associated with working with the same crew were highly beneficial in their return. This theme can also be seen as a form of social support or social connectedness.

One participant commented:

In the discussion of negative RTW factors, there were four subthemes identified. Half of the participants said that returning to work prematurely impeded the ability to have a successful return. Participants identified various reasons why they returned prematurely, including physical illness stigma, fear of financial loss, and ineffective RTW timelines.

Half of the participants discussed difficulties with anxiety leading up to and/or during their RTW, specifically questioning their physical and mental capacity to successfully return.

Two of these participants who had difficulties questioning their capacity aimed to simulate non-emergency firefighting scenarios as part of their recovery process. Both participants included physical training regimes in their SCBA gear before their RTW. They reported that including fire-specific training in non-emergency scenarios helped build their confidence and decrease symptoms of anxiety.

Half of the participants said that being treated “with kid gloves” upon their return to work was frustrating. Participants appreciated their peers’ concerns about their health because it showed that they cared, but it was a “double-edged sword” where they were frustrated constantly explaining the story, having people worry about their capabilities, and being treated “with kid gloves.” All participants who discussed this subtheme emphasized the importance of being treated normally during their return.

The last subtheme identified as a negative RTW factor was feeling let down by their employer during their treatment, recovery, and RTW due to a lack of support. This was discussed among all participants who did not report support from their department as a positive RTW factor (n=3).

Two participants discuss negative factors in RTW:

Lastly, we asked participants to discuss recommendations for an ideal RTW scenario for individuals with similar injuries. The most common recommendation, among six of eight participants, was to utilize social support from family, friends, peers, and people with similar experiences. Three participants specified that it is particularly beneficial to talk to fellow firefighters or public safety personnel who have had similar experiences, as they can understand and relate from a culturally competent lens.

Five of eight participants said that if they could give a fellow firefighter advice who is going through a similar experience, it would be to be kind and patient with yourself and trust the recovery process.

Similarly, Half of participants believed that people going through similar experiences should be encouraged to utilize mental health resources during their treatment, recovery and RTW.

Half also believed that being told by a department member or fellow firefighter to prioritize their recovery and take as much time as they need would be particularly beneficial in encouraging a successful recovery process and limit returning prematurely.

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A physical cardiac rehabilitation program tailored to firefighters (e.g., climbing stairs, hose carry/run, ladder carry) ^{[12, 13]}
Formalized mental health/wellness
Social support at the personal and organizational level ^[13]
A standardized re-entry process, including physical assessment and ability to return with modified duties ^[13]
Standardized and clearly communicated off-line procedures ^{[12, 13]}

Discussion: Recommendations for a Fire-specific Treatment, Recovery, and RTW

Based on the major themes that we identified among our sample we created several recommendations for what a fire-specific treatment, recovery, and RTW should include.

A physical cardiac rehabilitation program that is tailored to firefighters and their occupational tasks. For example, rehab exercises in turnout gear and fire-specific tasks including climbing stairs, hose carries, ladder carries, etc. Most participants did not have a mental or physical rehabilitation program tailored to firefighters, and did not feel their generic treatment and recovery plan prepared them to confidently RTW. We believe the inclusion of a fire-specific physical rehabilitation program will increase confidence and reduce RTW-related anxiety as participants can gain confidence doing workplace-specific tasks in a non-emergency environment.

Formalized mental health or wellness as part of their treatment process. Unsurprisingly, mental health/wellness was not considered or evaluated by healthcare professionals during diagnosis, treatment, or recovery. Meanwhile all participants reported adverse mental health outcomes.

3) Social support from one’s personal life and peers was the most reported positive factor during RTW and recommendation for a successful recovery and return. Participants highlighted the benefit of seeking social support from fellow firefighters or public safety personnel who have had a similar experience, and simply working with the same crew during their return. This theme highlighted that social support may come in various forms, and it does not necessarily need to take on the role of “peer support”; it can be as simple as engaging socially with your crew.

Social support from the organization was the only form of support that was reported as inadequate. Several participants reported feeling “let down” and that the lack of support from their organization had a negative impact during their recovery and RTW process. One participant had such a negative experience that they retired following their event. These results suggest that social support is a pillar in treatment, recovery, and RTW, and without it, there can be substantial negative impacts.

4) We suggest a standardized re-entry process that includes a physical assessment to determine if a member is ready to return to strenuous tasks and the ability to return with modified duties. Modified duties are disliked among firefighters in other studies (Killip et al., 2024). However, we believe modified duties allow the member to stay connected to their peers/the fire department, keep their routine, and continue to have a paycheck, which we believe contributes positively to a firefighter’s mental and social health. In our study, two participants who were put on modified duties believed it was a positive process to stay connected and gradually re-enter the workplace (note: this was not a large theme and was not reported in the main results); this result was also mimicked in another study from the UK.

We believe a standardized re-entry process with a physical assessment and ability to return to modified duties if a firefighter is not “combat-ready” may decrease premature returns, pushing themselves beyond their capacity, and promote mental and social health. It is important to acknowledge that this recommendation may not apply to volunteer departments, as they may not have the resources for a member to return to modified duties. We recommend that firefighters who cannot return to modified duties regularly engage socially with their department during their time off to promote mental and social health. For example, join in crew meetings/dinners, physical training drills, and access the firehall gym if available.

5) Lastly, similarly to our suggestion of a standardized re-entry process, we suggest there should be a standardized process of engaging with offline members. We believe communicating with the member about what their offline process looks like, what resources are available to them, and that the organization is here to support them both off and online would be beneficial. We suggest having a standardized offline and re-entry process that is clearly communicated with members at the time of going offline will set clear expectations for what a member can expect during their recovery and re-entry process. We believe this may remove ambiguities surrounding offline procedures and re-entry that can lead to feeling let down by the organization. Notably, this was also a finding and suggestion from Noll and colleagues 2022 and Killip and colleagues 2024.

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Lack of consideration of what it means to be a firefighter during treatment and recovery
Mental health implications following an acute cardiac event are overlooked and a major barrier to recovery and RTW
Physical illness stigma within the fire organization impedes a successful recovery and RTW
Social support is critical to a successful recovery and RTW
Need for a fire-specific treatment, recovery, and RTW

Conclusion

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References

[1] Soteriades, E. S., Smith, D. L., Tsismenakis, A. J., Baur, D. M., & Kales, S. N. (2011a). Cardiovascular Disease in US Firefighters. Cardiology in Review, 19(4), 202–215. https://doi.org/10.1097/CRD.0b013e318215c105

[2] Acute coronary syndrome. (2023, May 16). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/acute-coronary-syndrome/symptoms-causes/syc-20352136#:~:text=Acute%20coronary%20syndrome%20is%20a,known%20as%20a%20myocardial%20infarction.

[3] What Is a Stroke? (2023, May 26). National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health/stroke

[4] Stretton, S. M., & MacDermid, J. C. (2024). The Link between Stress and Cardiac Outcomes in Firefighters. In R. Ricciardelli, J. MacDermid, & L. Ferguson (Eds.), Occupational Stress Injuries (pp. 155–175). Routledge. https://doi.org/10.4324/9781003424253-12

[5] Angleman, A. J., van Hasselt, V. B., & Schuhmann, B. B. (2022). Relationship Between Posttraumatic Stress Symptoms and Cardiovascular Disease Risk in Firefighters. Behavior Modification, 46(2), 321–351. https://doi.org/10.1177/01454455211061320

[6] Soteriades, E. S., Smith, D. L., Tsismenakis, A. J., Baur, D. M., & Kales, S. N. (2011b). Cardiovascular disease in US firefighters: A systematic review. In Cardiology in Review (Vol. 19, Issue 4, pp. 202–215). https://doi.org/10.1097/CRD.0b013e318215c105

[7] American Psychiatric Association. (2017). Diagnostic and statistical manual of mental disorders: Dsm-5. Arlington, VA.

[8] Nazari, G., MacDermid, J. C., Sinden, K., D’Amico, R., Brazil, A., Carleton, N., & Cramm, H. (2020). Prevalence of exposure to critical incidents in firefighters across Canada. Work, 67(1), 215–222. https://doi.org/10.3233/WOR-203267

[9] Wagner, S. L., White, N., Regehr, C., White, M., Alden, L. E., Buys, N., Carey, M. G., Corneil, W., Fyfe, T., Matthews, L. R., Randall, C., Krutop, E., & Fraess-Phillips, A. (2020). Ambulance personnel: Systematic review of mental health symptoms. Traumatology, 26(4). https://doi.org/10.1037/trm0000251

[10] Yook, Y.-S. (2019). Firefighters’ occupational stress and its correlations with cardiorespiratory fitness, arterial stiffness, heart rate variability, and sleep quality. PLOS ONE, 14(12). https://doi.org/10.1371/journal.pone.0226739

[11] Smith, D. L., Haller, J. M., Korre, M., Sampani, K., Porto, L. G. G., Fehling, P. C., Christophi, C. A., & Kales, S. N. (2019). The Relation of Emergency Duties to Cardiac Death Among US Firefighters. The American Journal of Cardiology, 123(5), 736–741. https://doi.org/10.1016/j.amjcard.2018.11.049

[12] Killip, S. C., MacDermid, J. C., Thayalan, N., Lomotan, M., Gewurtz, R. E., & Sinden, K. E. (2024). Exploring Canadian Career Firefighters’ Understanding of the Return-to-Work Process After Musculoskeletal Injuries. Journal of Occupational Rehabilitation, 34(3), 582–593. https://doi.org/10.1007/s10926-023-10147-x

[13] Noll, L., Mallows, A., & Moran, J. (2022). Psychosocial barriers and facilitators for a successful return to work following injury within firefighters. International Archives of Occupational and Environmental Health, 95(2), 331–339. https://doi.org/10.1007/s00420-021-01712-z

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