By Brittany Hollerbach and Todd LeDuc
Head injuries have been receiving increasing attention nationally as sports—from children’s extracurricular activities to professional football—have identified the extreme consequences of even minor traumas. Issues with memory, cognition, and physical and emotional health are often reported related to head injury1 with severe deleterious effects. Protocols have been developed to identify and appropriately respond to risks and research in this area are blossoming. Emerging data is reinforcing the risk of even a single acute incident and the exponentially increased dangers of repeated and untreated injuries2. Despite this increased interest in the public setting, the national fire service has remained relatively silent and unprepared for the unique risks of head injuries on scene and the consequences off scene. It is past time for a national effort to address this disparity.
- Concussions: Assessing the Risk for Firefighters
- Sports Injuries in Children and Young Adults: Concussions
Head injuries are common in the fire service. According to the U.S. Fire Administration’s National Fire Incident Reporting System (NFIRS), in conjunction with the annual fire experience survey administered by the National Fire Protection Association (NFPA), over a five-year period from 2015 to 2019, 11% of injuries reported (the third most common) were due to head injury3. Firefighters are exposed to ceiling and building collapses, have to navigate through smoke-filled environments unable to see and hitting walls and other items impacting the head first. While head injuries are common, little guidance exists for reporting, recording, appropriately responding to, and managing head injuries or examining potential neurologic deficits throughout a firefighter’s career.
We know that firefighters experience repetitive head/brain trauma throughout their careers or volunteer involvement. Often, these injuries go unreported as the danger of such events are under recognized. While other high-risk populations have been increasingly vigilant in their recognition and treatment of head injuries, no standardized protocols exist for firefighters to identify, monitor and appropriately respond to injuries. A program that trains firefighters and departments on head/brain injuries, an established protocol to report these injuries, on-scene concussion evaluation, and the appropriate treatment approaches are needed to decrease the long-term impact of these injuries and their related sequela.
As evidenced in studies related to professional sports (National Football League [NFL], National Hockey League [NHL]) as well as college and youth sports, repetitive head injuries lead to jarring of the brain and produce physical and neurologic injuries. Research has found that 76% of firefighters report at least one head injury in their lifetime4. Some injuries are minor yet some are more serious, directly impacting the firefighter’s brain and potentially leading to long-term consequences. In a cross-sectional study, symptoms of post-traumatic stress disorder (PTSD) were significantly more severe among firefighters with a line-of-duty head injury compared to both firefighters with no head injury and those with a non-line-of-duty head injury4. While research specific to firefighters is evolving, there exists a number of resources in occupational groups with similar risk profiles. However, the research is primarily in the peer-reviewed medical literature and is, therefore, inaccessible to most of the fire service.
Sport-related concussion (SRC) is a mild traumatic brain injury (mTBI) sustained during sports, which is clinically diagnosed and associated with negative standard head imaging, when performed8. The cost of mild or traumatic brain injury among firefighters is not well documented. However, American tackle football was associated with $1.35 billion in healthcare costs from 2010 to 20139. Although this value encompasses more than just head injury, outpatient care was not included, resulting in an underestimation of the total cost of football-related injuries9–12. In a retrospective claims analysis of mTBI patients over a 12-month period, mean follow-up health-care costs were $13,564 (SD = $41,071), primarily from inpatient ($4,675, SD = $29,982) and non-ED outpatient/physician office visits ($4,207, SD = $12,697).
So where do we go from here? Well, the answer most uniquely lies in the work of professional sports world and military. Re-evaluation of our PPE to assure the most robust head and neck protections, on-scene concussion protocols, and incorporating head trauma/TBI screening into our annual medical physical/evaluations are a start.
REFERENCES
1. McCrory P, Meeuwisse W, Dvorak J. et al. Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016. Br. J. Sports Med. 51(11), 838-847 (2017). [PubMed] [Google Scholar]
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7. Wilkins SA, Shannon CN, Brown ST. et al. Establishment of a multidisciplinary concussion program: impact of standardization on patient care and resource utilization: clinical article. J. Neurosurg. Pediatr. 13(1), 82-89 (2014). [PubMed] [Google Scholar]
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9. Leddy JJ, Haider MN, Ellis MJ. et al. Early subthreshold aerobic exercise for sports-related concussion: a randomized clinical trial. JAMA Pediatr. 173(4), 319-325 (2019). [PMC free article] [PubMed] [Google Scholar]* A well-designed trial demonstrated that early aerobic exercise is associated with a 4-day decrease in recovery time and about 10% risk reduction in delayed recovery.
10. Rowson S, Duma SM, Beckwith JG. et al. Rotational head kinematics in football impacts: an injury risk function for concussion. Ann. Biomed. Eng. 40(1), 1-13 (2012). [PubMed] [Google Scholar]
Todd LeDuc, MS, CFO, FIFirE retired as the executive assistant chief of Broward County, Florida, and joined Life Scan Wellness Centers as their Chief Strategy Officer. He is a reviewer or both professional credentialing and agency accreditation with the Center for Public Safety Excellence and advisory board member of the First Responder Center of Excellence. He is a longtime board member of the International Association of Fire Chief’s Safety, Health & Survival Section and a technical committee member of the NFPA Standard on Occupational Health of First Responders. He is also the editor of the Fire Engineering book, Surviving the Fire Service.
Brittany Hollerbach, Ph.D., is an Associate Scientist at NDRI-USA, Inc and Deputy Director for the Center for Fire, Rescue & EMS Health Research (CFREHR). She received her Ph.D. in Kinesiology from Kansas State University and recently completed a postdoctoral research fellowship at Skidmore College under the direction of Dr. Denise Smith, where she focused on cardiovascular disease in the fire service. Dr. Hollerbach has extensive experience working with the fire service on a number of federally funded firefighter studies conducted by the CFREHR and the Center for Military and Veteran’s Health Research. She recently received FEMA funding as the PI on a project examining firefighter perceptions of protective strategies used to mitigate the spread of COVID-19. Dr. Hollerbach has an interest in firefighter health in general and female firefighter health specifically, given her background as a former firefighter. She also has experience teaching at the fire academy and is well-connected to the fire service community in Kansas City.
This commentary reflects the views of the author and not necessarily the views of Fire Engineering.
