Photo by Tony Greco.
By Chris Lorenz
As I watched the Fire Engineering/MSA podcast on cardiovascular/carcinogenic exposure risks for firefighters, I felt compelled to share my story. I have the unfortunate experience of being able to speak on this subject firsthand, but I am fortunate that I am still around to talk about it.
In June 2013, I was part of the first-arriving company on a wind-driven fire in the overhead of a large, three-story apartment complex. My crew’s assignment was to extend an attack line to the 3rd floor, force entry, and locate and extinguish the fire.
Once inside, we found the overhead heavily involved. I breached the ceiling, pulled a table over, climbed up, and began extinguishment. Because of the construction of the attic space, I needed to pull myself up into the attic space, which momentarily displaced my face piece and helmet. Once in place I began knocking down the fire in all the areas I could access. I noted that the remainder of the fire was behind a wall that I could not access from my perch. I dropped back into the kitchen, and we moved cabinets so I could climb up, open up the wall section, and knock down the rest of the fire.
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This was an aggressive fire attack that, if we had not gone at full bore would have spread throughout the entire complex. Pulling myself up into the attic space required maximum effort and got my heart beating hard. When I pulled off my mask, the breath of smoke did not help matters. I began to feel winded, more than I should have been. I began to get pain in my chest and left shoulder blade. The harder I pushed, the worse the pain got.
As the next crew arrived to relieve us, I felt wiped out. I was winded and my chest ached. We were sent to rehab, and I was very restless. I could not sit still and continued to find work to do. I felt “off” the remainder of the shift.
You may think that I should have reported it and went to the emergency room (ER) because I showed “classic heart signs.” This is where my story is different. I was a very fit 6’1”, 200-pound firefighter.
In August 2009, during an overhaul of a residential fire, I had a similar pain in my left shoulder. I thought I had pulled a muscle. It bothered me all night, and I was working overtime the next day. It got worse throughout the next day, and again I got a little winded. The crew worked me up, and my 12-lead showed a posterior fasicular block, so I was transported to the ER.
The doctors ran all kind of tests and told me my heart was as healthy as an 18-year-old’s. My arteries were clear. I subsequently passed my treadmill and was told it was a muscle strain.
Over the next several years, the pain would return. Occasionally, I would feel very lethargic. Since I was told that my heart and arteries were healthy, I assumed the pain was muscular and that I just needed to train harder and exercise more.
Back to the summer 2013—after the fire, I got this very strange feeling in my chest. It was like getting your breath taken away when you jump in ice water. This happened several times the following month, and a few times I got lightheaded.
Later that August, I was conducting a large-scale training exercise for the department using a city block that was to be demolished. It had been a very busy week between teaching and running calls. I was feeling very weary toward the end of the week, so much so that on the final day I commented to my partner that, “If I felt the same as I did yesterday, I am not sure I’ll make it through shift.”
At the exercise, I demonstrated some masonry wall breaching and scaling techniques that we had done all week without difficulty, but this time, the exercise wiped me out and made me feel that I had climbed a mountain. It was so bad that I knew I couldn’t finish the shift, and that something was definitely wrong.
I violated range rules. I had my partner continue to teach, taking the group into the buildings to discuss interior construction while I slipped off back to the apparatus. I checked my vitals. I was slightly tachycardic, pressure was okay, and the four-lead had slightly elevated “T”’ waves. I assumed I was dehydrated and hot from the long week. I hydrated and peeled of my gear. Ten minutes later, nothing had changed. I hooked myself up to the 12-lead and, as I hit “Analyze,” the guys, who had noticed I was AWOL, came looking for me.
The strip printed out, and one of them grabbed it before I could and said, “You are going to the ER.” A discussion ensued where I was outranked and outvoted. The strip showed a posterior fascicular block, same as it had four years ago.
Typical of an ER visit, by the time I was attended to, everything was normalizing except my cardiac enzymes, which were borderline. The doctor said that this could be the result of exertion. I was a healthy, fit guy with no risk factors. The doc told me that, just to be safe, he was going to admit me, and I would run a nuclear treadmill test in the morning.
(From my experience, know that you do NOT want to spend the night at the hospital with a cardiac diet restriction. I had not eaten all day. So, for dinner I had chicken noodle soup; it came with two noodles, a piece of meat, and no crackers or salt.)
In the morning, I did great on the treadmill, but I did feel a little winded and had some slight chest pain. The doc said that I did well and everything looked good. As per protocols for the nuclear test, the doctors injected me with dye and took x-rays immediately after my treadmill run. As soon as the images from the nuclear test came back, I was to go home.
As I was gathering my things to go home, the floor doc came to my room with another doctor. He introduced this doctor as the man who would be performing my cardiac catherization.
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My situation went from “All is well and you’re going home” to “It appears you have a major blockage in the back of your heart.” This cardiologist ensured me that I would feel much better after the procedure and I would be 100 percent and back to work in several weeks.
As I laid on the table, listening to the doctor as he guides the catheter through my heart, he says that comments, “That’s odd; your arteries are big and clean.” I replied, “That’s good, right?” He said yes, but he was expecting to find a major blockage based off the amount off ischemia visible on the nuclear images.
He then says, “Oh, there is a large aneurysm.” That is not good. I then was moved to the echocardiogram room, where workers took another image of the aneurysm. I was sent back to my room, and the nurses were trying to reassure me about getting my chest cracked open the next day.
Needless to say, I did not sleep much. I wrote a note to my wife and kids on a paper towel just in case something bad happened. The next morning, after further review, doctors decided the aneurysm was smaller than they thought.
I had subsequent tests which raised only more questions. During this period, I kept having a weird feeling in my chest and the occasional light-headedness. I knew if I mentioned the lightheadedness, I would definitely not get cleared back to the line. As the doctors reviewed all the tests, they came across the CT results from 2009; they could see the very beginning of the injury on those films, and it was missed by the doctors at the time.
My left ventricle was now mostly scarred over. In the process of scarring over, it adhered itself to the pericardial sac. The aneurysm formed as a result of pushing myself through what I thought was muscular pain and shortcomings in my conditioning at the apartment fire. The aneurysm started runs of ventricular tachycardia (that “funny” feeling in my chest), which caused everything to come to a head. I was pulled off the line and began working days while the doctors came up with a game plan for me.
They preferred me to retire. I explained that there were several problems with that plan. First, I love to work and do my job. Second, in Washington State, the system will not treat you fairly unless you prefer to live off the system, in which case they will give you a “gold card.” The more immediate problem was that I was at a high risk of sudden cardiac death because of the injury. This meant I had to have an implanted cardioverter defibrillator (ICD); this is, typically, the end of the line for firefighters. The cardiologists will not clear you for duty with the traditional ICD, because, among other reasons, it is placed inline of the pack straps; there are fragile wires running into the heart, and the risk of damaging the device in our job is high.
My electrophysiologist fought long and hard to get a device which was considered experimental. It had been used in Europe for close to a decade and in the U.S. for half that time. It is a rugged device (S-ICD) which is placed under the left arm, and no wires go into the heart. It is only a defibrillator. The insurance companies did not want to pay for it (the cost was actually less than the traditional ICD) because it was experimental, even though not getting it meant I would be unemployed. In the meantime, I had to wear an external defibrillator, which the guys at my house affectionately coined my “bra and purse”’ for five months.
As bad as things were, I had several things going in my favor. I had excellent, supportive doctors. I had been in extremely good physical condition, so my heart was larger and more efficient. Thus, when I injured it and lost that cardiac function, I still had the reserves to function at acceptable level. I never smoked, I was height and weight proportionate, healthy, and I had no family history. These issues are also ones which our state examines for consideration under the following presumptive language for firefighters.
RCW 51.32.185
Occupational diseases — Presumption of occupational disease for firefighters — Limitations — Exception — Rules.
“This presumption of occupational disease may be rebutted by a preponderance of the evidence. Such evidence may include, but is not limited to, use of tobacco products, physical fitness and weight, lifestyle, hereditary factors, and exposure from other employment or non-employment activities.”
This is another big reason why you owe it to yourself, your family, and your work family to stay fit and healthy. I still had a long road and an uphill fight to get cleared back for duty, but I had no plans to go without a fight. If I was going out, it would be on my terms. My biggest fight, as it turned out, was getting the injury covered by my insurance.
Although I was still in the hospital, the state claimed that my injury was not job related. At this point, I had not even been worked on by the cardiologist. Hospital billing had access to my private insurance, so they sent the bills to them.
What happened over the following two years makes following the flow of the Amazon from its source to the ocean appear simple! My insurance paid for some things such as labor and Industry, it paid for a few initial things after a fight, and we set up payments on the others. It took nearly two years to get Labor & Industries (L&I) to accept and start paying bills. The irony is that it is clearly delineated in the Revised Code of Washington regarding cardiac injuries for firefighters at work, and the state still fought it.
L&I eventually sent me to see their “expert” cardiologist for an exam. When I saw their expert, it was obvious that he had not read the reports, nor was he familiar with my occupation. The following are several quotes from his report that he sent L&I:
According to the state, expert firefighters are never exposed to smoke, toxins, or viruses at work, nor are there known connections to physical exertion and heart injuries.
At this point, I went to an attorney; it had been close to a year of dealing with this issue. Then, it was almost another year before things began to get resolved. The state Attorney General’s Office didn’t even agree with their client, L&I, but L&I was insistent on fighting it. The staggering medical bills, the constant worry of whether or not I will have my career, and the continuous battle with the system to get things resolved can wear one out. We may have to watch L&I videos about workplace bullying, in which they really want you to understand that it can lead to real medical problems, but having real medical problems can’t be made worse by bureaucratic bullying?
I eventually got myself cleared back to duty without any help from the “system.” I have been left with an approximate 20 to 25-percent loss in cardiac output. I am not supposed to “work hard,” lift heavy weights, and participate in endurance sports. The doctors wanted me to retire, but when I explained that, in Washington State, if you can ask “do you want fries with that?’ They will consider you gainfully employed regardless of your prior occupation.
It was imperative I get cleared for full duty. Since I had been very fit before the loss of my heart function, I was left with ample reserves to do the job. I could still pass my treadmill test and perform my essential duties. The doctors were willing to release me and keep me “on a short leash” so long as everything stayed stable, with the goal being not to increase the size of the aneurysm, scarring, or further loss of cardiac function. One of the big factors in damaging any body system, especially the heart, is inflammation.
Inflammation results from all kinds of things such as stress, hard work, exercise, and lack of sleep. Unfortunately, that is our job description. I live on anti-inflammatories now. I try to adjust my life to minimize and control those factors which I can. I live with frequent chest pain; some days are worse than others. I have to be careful what I tell the doctors so I do not put them in a bad spot.
Another reason I wanted to be cleared with my S-ICD for a return to duty and, once cleared, showed that it could be successful is for those that may come after me. The S-ICD may not be the answer for everyone in a similar situation, but if it is needed, then it sets the precedent that it will not necessarily end your career.
I have to balance all this to support my family, staying fit, doing my job, not letting my brothers and sisters down, and fighting the insurance companies and the state. I may never know which day may be my last at work because the doctor has changed his mind or I had a bad day at work.
The doctors say they will never know exactly what I was exposed to at the fire. So, now that the injury has stabilized and I have been back “online” for close to a year, I have to continue to watch what I do and how I do it. I can keep working, watch my kids grow up, and hopefully enjoy retirement when that day comes.
There are many things that can hurt and kill you on the job. You owe it to yourself to wear your personal protective equipment, use it properly, be in the best physical condition, and stay sharp technically. If we fail at our mission or are either hurt or killed on the job, never let it be said that it was because a lack of training, physical conditioning, or preparation.
Chris Lorenz has been in the fire service since 1998 and is a 15-year member of the Central Pierce (WA) Fire & Rescue. Lorenz has also a member of the CPFR & RIT Bag Extrication Teams that competed and placed in regional TERC events in 2005, 2006, and 2007, and competed in the 2006 and 2007 TERC Nationals. He has also been an instructor and competed with PXT since 2006.
Lorenz serves as member of the Pierce County Law Enforcement/Fire Joint Training Consortium which has spearheaded the regional joint training & response to active shooter events for over a decade as well as other cooperative operational and training objectives. Teaching at local, regional, state, and federal levels. He has served as a SWAT Medic since 2004. He is also an instructor for the Puyallup Extrication Team and instructs in forcible entry and with active shooter rescue teams. He is also a fusion liaison officer. He specializes in auto extrication, technical heavy extrication, active shooter rescue. Lorenz is also a SWAT medic.
