First Responders

First responders are primarily police, fire, and emergency medical services (EMS) personnel, but the term is also often used to include other emergency services personnel (e.g., State Emergency Services [SES] in Australia); health care personnel (who are first to receive the victims in the emergency department); and public health professionals who prevent disease outbreaks, conduct outbreak investigations, and inspections. This chapter focuses on the health and safety of workers who are involved in the initial and prehospital response to a disaster: first responders (firefighters, police, and paramedics); secondary responders; and skilled support personnel, such as heavy equipment operators. These first responders are deployed in a forward position and are expected to put themselves in situations where they may be exposed to potentially life-threatening hazards.

The overriding priority of first responders is to protect the victims and to secure the location. They rescue or otherwise protect others who are not able to save themselves. Protecting property from destruction or damage is a secondary objective, to be attempted if the personal risk is acceptable. In order to achieve these priorities, first responders allow themselves to be exposed to hazards, resulting in risks that would be unacceptable in other occupations. In order for this exceptionally high risk to be acceptable, the risk is managed by a combination of hazard controls (equipment), personal protection (e.g., self-contained breathing apparatus [SCBA] and “turnout gear”), administrative controls (two-officer rules and backup calls), risk assessment (determining the risk to victims and to responders of the incident and various options for controlling it), training, and fitness-for-duty standards.

The capacity to do the work of first response is essential. Without the requisite physical and mental capacity, the first responder will fail in his or her role in the mission and will become a casualty themselves, and therefore impose a burden impeding the response. Occupational safety and acute health protection then preserves the capacity of the individual to do his or her essential job and prevents degradation of the group capacity to achieve the mission; it also prevents the responder from becoming a casualty requiring care. Occupational health protection against chronic health effects and disability, and the provision of fair compensation for occupational disease and disability rising from work, provides assurance that the risk the responder has assumed will be mitigated, if there is an untoward result.

Fitness-for-duty standards are medical criteria for screening workers to ensure their physical capacity to do a specific job, with or without accommodation (such as eyeglasses for driving). For first responders, fitness-for-duty standards may include tests of vision, strength, coordination, stamina (for firefighters, treadmill cardiac stress testing), and evaluation for disorders that may affect readiness or impair judgment (for example, insulin-dependent diabetes and the risk of hypoglycemia). Fitness-for-duty evaluations must conform to applicable persons with disabilities acts, such as the Americans with Disabilities Act, to the extent that disability can be accommodated. However, medical standards for public safety personnel are usually higher and more inflexible than in other employment sectors. This is because public safety personnel must be able to operate at peak capacity under adverse conditions for prolonged periods, and do so without degrading performance or endangering the public safety (e.g., if carrying a firearm). In order to protect their jobs during periods of short-term partial disability, public safety personnel often have elaborate temporary assignment plans or informal “light duty” options as a resort if they are temporarily unfit for full duty. Recommended medical standards have been formulated by national standards organizations such as the National Fire Prevention Association (for firefighters), professional societies such as the American College of Occupational and Environmental Medicine (for law enforcement officers [LEOs]), and in some cases by private organizations. Government agencies have also formulated their own medical standards, for example, California’s Commission on Peace Officer Standards and Training. These standards are adopted, in whole or in part, and operationalized by the agencies involved, given the resources available locally.

In addition to the public safety professionals, many private individuals and volunteers may also be involved in disaster response but may have different levels of capacity and preparation. For example, volunteer firefighters may not be held to the same medical standards as paid firefighters. The health protection of volunteers should also be considered in the medical response. In addition to their own health and safety, volunteer responders are also likely to be facing the same consequences as the rest of the community in a large-scale disaster. They may be blocked from reaching the scene by the same traffic obstacles or detours and may struggle to secure their own families in an area-wide emergency. Often, volunteers are used as a reserve to fill in the gaps in coverage left when paid crews are deployed to the scene. For example, volunteer firefighters may take over municipal firefighting duties while the paid fire service is occupied with a multialarm, multiple-station response. Because volunteers have less frequent call-ups and usually do not adhere to the same fitness standards as the regular paid service, they may be at higher risk for injury and health risks while deployed. Occupational health protection should be the same for volunteers as for regular line officers, and during the response their integration should be immediate, well practiced, and seamless.

First responders are generally the second to arrive on the scene, after concerned passersby and neighbors who rush to provide immediate assistance. In an area-wide disaster, the first responders may live in the communities affected. The occupational risks of first responders include the same hazards that threaten the victims, with the addition of the occupational hazards of the job. Because they often arrive before the site has been secured, decontaminated, or thoroughly searched, first responders may themselves face threatening situations on arrival. For example, the first arrivals at the site of a terrorist bombing must face the real possibility of a second explosive device intended for them. Even after the site is secured, first responders are confronted with events and circumstances outside the usual experience of human beings in their daily lives.

Although each of the occupations that constitute first responders has its own set of hazards, risks, and traditions, first responders share several features in common, including

• •
  

  an awareness of personal danger, often accompanied by coping mechanisms that may include denial;

  
  
• •
  

  long periods of relative quiet or routine interrupted abruptly by periods of intense activity, often accompanied by psychological stress;

  
  
• •
  

  rigid codes of behavior and high expectations for performance, often accompanied by complicated job responsibilities and guidelines and high penalties for failure;

  
  
• •
  

  a strong ethic of teamwork and camaraderie, always with a strong sense of mutual reliance, reinforced with social penalties for letting down one’s co-workers; and

  
  
• •
  

  a rigid hierarchy or “chain of command,” often paramilitary, which is necessary in order to reduce uncertainty and to make sure that procedures are followed correctly.

Firefighters

During a disaster, firefighters may be exposed to unusual hazards in addition to the more conventional risks of fighting fires. Fires are often part of the disaster, of course, but the skills and training of firefighting also apply to rescue, extrication, identification of hazardous materials, fire prevention, and, for an increasing number of fire departments in the United States, EMS. Versatility is required. In addition to traditional fire and rescue, firefighting skills and technology may be called into play in unusual ways when circumstances require.

There are four common varieties of firefighters and several specialized classifications. Municipal firefighters respond to calls in populated areas and encounter both conventional structural fires and exceptional incidents in industrial settings that present a high risk for chemical exposure; municipal firefighters typically experience at least one or two of these over the course of a career. Woodland firefighters respond to fires in open areas, such as forests and range; they deploy as teams, and when things go terribly wrong, casualties are multiple and usually fatal. Industrial firefighters may be full time at a particular location or for a particular employer but are often operations workers cross-trained to respond to emergencies in a particular setting, such as an oil refinery; mine rescue is a highly prestigious subset of these responders. Aviation firefighters deal with structural fires on the ground and with aviation emergencies at civilian airports and in the military; municipal fire departments usually have aviation units permanently deployed at airports in their service area but not at smaller air fields serving general aviation. Within the fire service, firefighters may receive special training in hazardous materials recognition and assessment (HazMat) that places them at a different risk profile than other firefighters. In many major urban fire departments today, a large proportion of firefighters are cross-trained as emergency medical technicians (EMTs) and can work in either capacity.

Occupational hazards experienced by firefighters may be categorized as physical (mostly unsafe conditions, thermal stress, and ergonomic stress), chemical, and psychological. Firefighters responding as EMTs may also face biological hazards. The level of exposure to hazards during knockdown and overhaul depends on what is burning, the combustion characteristics of the fire, the burning structure, the presence of nonfuel chemicals, the measures taken to control the fire, the presence of victims requiring rescue, and the position or line of duty held by the firefighter while fighting the fire. The hazards and levels of exposure experienced by the first firefighter to enter a burning building and engage in fire suppression, called “knockdown,” is different from those of the firefighters who enter later to search for smoldering fuel that could flare up, a process called “overhaul.” In general, the former is exposed to greater risk of trauma and the latter is exposed to more hazardous chemicals by inhalation.

The energy requirements for firefighting are high and complicated by the severe conditions encountered in many inside fires. The metabolic demands of coping with retained body heat, heat from the fire, and fluid loss through sweating add to the demands of physical exertion. Firefighters adjust their levels of exertion in a characteristic pattern during simulated fire conditions, as reflected by heart rate. Initially, their heart rate increases rapidly to 70% to 80% of maximal within the first minute. As firefighting progresses, they maintain their heart rates at 85% to 100% of maximal.

During firefighting, core body temperature and heart rate follow a cycle over a period of minutes: they both increase slightly in response to work in preparation for entry, then both increase more as a result of environmental heat exposure, and subsequently increase more steeply as a result of high workloads under conditions of heat stress. After 20 to 25 minutes, the usual length of time allowed for interior work by the SCBA used by firefighters, the physiological stress remains within limits tolerable by a healthy individual. However, in extended firefighting involving multiple reentries, there is insufficient time between SCBA air bottle changes to cool off, leading to a cumulative rise in core temperature and an increasing risk of heat stress.

Firefighters exert themselves to maximal levels while fighting fires. The most demanding activity is building search and victim rescue by the “lead hand” (first firefighter to enter the building), resulting in the highest average heart rate of 153 beats per minute and highest rise in rectal temperature, 1.3 °C. Serving as “secondary help” (entering the building at a later time to fight the fire or to conduct additional searches and rescues) is the next most demanding, followed by exterior firefighting, and serving as crew captain (directing the firefighting, usually at some distance from the fire). Other demanding tasks, in decreasing order of energy costs, are climbing ladders, dragging hose, carrying a traveling ladder, and raising a ladder.

Risk varies with the activity. From the first alarm, firefighters are at transiently elevated risk of cardiovascular events with a relative risk (compared to routine duties) over three, and highly statistically significant. During fire suppression, the increased risk of cardiac events rises to 32 times the risk while performing nonstrenuous routine activities, a reflection that firefighters are under stress despite their medical standards and fitness requirements. ^,

Injuries associated with firefighting are predictable: burns, falls, and being struck by falling objects. Injuries can be minimized by intensive training, job experience, strict preplacement screening to ensure work capacity, competency on task, and physical fitness. However, the nature of the job is such that firefighters face dangerous situations by miscalculation, circumstance, and especially during rescues. The structure that a firefighter enters is not only on fire but often weakened structurally. Walls, ceilings, and floors may collapse abruptly and trap firefighters or cause them to fall. Exposed wires may present a risk of electrocution. Holding the nozzle runs a risk of severe scald burns from hot water. Turnout gear is designed for protection against burns and radiant heat, and so burn injuries tend to be the result of more complicated factors, such as basement fires, recent injury prior to the incident, and training outside the fire department of present employment. Falls tend to be associated with SCBA use, ladder work, and assignment to truck companies.

Obviously, burns are a leading class of injury to firefighters, although standard turnout gear is very effective in minimizing the risk of burns. “Flashovers” are explosive eruptions of flame in a confined space that occur as a result of the sudden ignition of flammable gas products driven out of burning or hot materials and combined with superheated air. Fire situations that lead to flashovers may engulf the firefighter or cut off escape routes. Hot air by itself is not usually a great hazard to the firefighter. Dry air does not have much capacity to retain heat. Steam or hot, wet air can cause serious burns because much more heat energy can be stored in water vapor than in dry air. Fortunately, steam burns are not common. Radiant heat is often intense in a fire situation. Burns may occur from radiant heat alone. Firefighters may also show skin changes characteristic of prolonged exposure to heat.

Improvement in turnout gear and the introduction of SCBAs and other protective equipment within the last 20 years have created much safer working conditions for the firefighter. However, the added weight of the equipment increases the physical exertion required and may throw the firefighter off balance in some situations. The firefighter’s typical turnout gear may weigh 23 kg and imposes a high energy cost. The protective clothing also becomes much heavier when it gets wet. A 20% decrement has been found in work performance imposed by carrying SCBAs, a substantial restraint under extreme and dangerous conditions.

Under fire conditions, these physical demands are complicated by the metabolic demands of coping with heat and loss of fluids. The combined effect of internally generated heat during work and of external heat from the fire may result in markedly increased body temperatures that climb to unusually high levels in an intense firefighting situation. Half-hour interval breaks to change SCBAs are not enough to arrest this climb in temperature, which can reach dangerous levels in prolonged firefighting. Although essential, personal protection imposes a considerable additional energy burden on the firefighter, particularly SCBAs.

Heat stress during firefighting may come from hot air, radiant heat, contact with hot surfaces, or endogenous heat that is produced by the body during exercise but which cannot be cooled during the fire. Heat stress is compounded by the same insulating properties of turnout gear that provide protection and by physical exertion, which result in heat production within the body. Heat may result in heat exhaustion, with the risk of dehydration, heat stroke, and cardiovascular collapse.

Ordinary firefighting may be associated with short-term changes similar to asthma, resolving over days, but does not appear to result in an increased lifetime risk of dying from chronic lung disease. However, unusual exposures, such as intense exposure to the fumes of burning plastics, can cause severe lung toxicity, reactive airways disease (where none existed before), and even permanent disability. The risk is substantially reduced with appropriate use of SCBAs.

Over 50% of fire-related fatalities are the result of exposure to smoke, rather than burns. One of the major contributing factors to mortality and morbidity in fires is hypoxia because of oxygen depletion in the affected atmosphere, leading to loss of physical performance, confusion, and inability to escape. The constituents of smoke, singly and in combination, are also highly toxic. The toxicity of smoke depends primarily on the fuel (synthetic materials produce more toxic smoke, especially where there is a rich chlorine source), the heat of the fire (lower temperatures produce more toxic components), and whether or how much oxygen is available for combustion (rich fuel mixtures tend to produce more polycyclic aromatic hydrocarbons and particulate matter). Only carbon monoxide and hydrogen cyanide are commonly produced in lethal concentrations during structural fires. Depending on the fuel, firefighters may also be exposed to high levels of nitrogen dioxide, sulfur dioxide, hydrogen chloride, and irritating chemicals such as aldehydes. SCBAs substantially reduce exposure to these short-term hazards.

Cancer risk is also elevated among firefighters for certain cancers, particularly those associated with inhaled carcinogens. Firefighters are regularly exposed to carcinogenic hazards, including polycyclic aromatic hydrocarbons and nitroarenes, 1,3-butadiene, benzene, formaldehyde, polyhalogenated compounds (trichloroethylene, polybrominated fire retardants, polychlorinated biphenyl compounds, dioxins, and furans), and asbestos. SCBAs substantially reduce exposure to these cancer hazards.

SCBAs are an effective personal protection device that prevents exposure to the products of combustion when used properly. Fire services routinely require the use of SCBAs during overhaul but individual firefighters often ignore the requirement and wear it only during knockdown. This is in part because SCBAs, while much improved, are uncomfortable, heavy, bulky, elevate the firefighter’s center of gravity, impede communication, and obscure vision; necessary as they are, they are not something one would choose to wear in an environment with unstable footing and low visibility. Firefighters tend to judge the level of hazard they face by the intensity of smoke and decide whether to use a SCBA solely on the basis of what they see. This may be very misleading, especially after the flames are extinguished. There is no apparent correlation between the intensity of smoke and the amount of carbon monoxide or cyanide in the air.

The psychogenic responses of firefighters to stress associated with catastrophic situations are probably similar to that of other public safety occupations but generally better characterized in the literature. Losing a victim during attempted rescue is particularly difficult for a firefighter, but during a disaster such losses may be inevitable. It is clear that PTSD is not the only or even the most common response to shocking events, although it has been the focus of attention. Depression and self-medication with alcohol are probably more common, and most common of all may be somatization, as suggested by studies that show a high frequency of multiple health complaints without evidence of disease among responders to horrific events. Although it continues to have advocates, critical incident stress debriefing, once thought to be effective in preventing PTSD and other dysfunctional responses, has been abandoned in favor of “psychological first aid” and ready access to psychological support for firefighters who self-refer.

Police

In a disaster, police will have several functions: (1) establishing and maintaining order at the scene; (2) protecting the safety of the population at risk in the vicinity of the disaster; (3) protecting the safety of other responders; (4) maintaining the integrity of the scene if a criminal investigation is involved; and (5) in many cases, rescue assistance. In a disaster, one of the most important functions of the police is to maintain the security of the disaster scene from well-meaning volunteers who may inadvertently put themselves and others at risk. Although they are frequently first or second on the scene, police officers may not necessarily have access to the same level of PPE as other first responders, and the nature of their work can make it more difficult to consistently use PPE. The nature of the police force is such that in some cases, it may be challenging to ensure that all potentially exposed police officers participate in post-event medical management and follow-up.

Police, who are also known as LEOs (a term that also includes other protective services, such as correctional officers), have a number of potentially significant exposures, including injuries (both violent and from physical activity); hazardous air pollutants, including lead, noise, radio frequency radiation from radar; and psychological stressors, including violent trauma, shift work, and sleep disruption. There are relatively few studies of cancer risks among police officers, and those that exist do not indicate a consistent pattern of increased risk, though some association has been noted for thyroid, skin, and possibly male breast cancer.

In the wake of the September 11, 2001, attacks, the rates of injury for police workers were comparable to those of other emergency responders. Other studies have reported inconsistent results in comparing firefighters to police with respect to exposures or symptoms. Police frequently have exposures that are similar to other emergency responders, even though they may not always be equipped with the same degree of PPE.

LEOs are often engaged in difficult situations that may involve physical exertion (e.g., in restraining suspects) and that presents risks to the public (e.g., when carrying a gun if the officer is disoriented or cannot see well, or is overwhelmed and loses control of the weapon). Their health status and functional capacity is therefore a matter of public safety; LEO positions are considered “safety-sensitive.” A national set of evidence or expert consensus-based guidelines (when evidence is not sufficient) for the screening and health surveillance of LEOs has been developed by the American College of Occupational and Environmental Medicine and is available online, where it is updated as a subscription service. These guidelines specify levels of capacity required to perform LEO duties, to qualify an officer to carry a weapon (including conditions that may affect judgment and aim), and for prevention of conditions that could result in sudden incapacity, for example during an altercation or pursuit.

Emergency Medical Services Personnel

EMS personnel include paramedics, EMTs, and other prehospital care providers. These personnel treat an estimated 30 million patients a year in the United States. ^, In addition, they are first responders to natural and human-made disasters and are a crucial component of the nation’s disaster response system. Although prehospital care personnel have been operating in the United States for over a century, it is only recently that the full range of risks associated with this work have begun to be investigated. Research has shown that the occupational fatality rate for this group is more than twice the national average and comparable to the rates for police and firefighters. The rate of nonfatal occupational injuries and illnesses may be more than five times the national average. The risks are largely associated with transportation events, lifting, and violence. Similar risks have been found among paramedics in Australia. Because these risks are only now being recognized, EMS personnel and managers, as well as town council members and mayors, are largely unaware of the extent of the dangers associated with the work.

Historically, the role of EMS was to provide on-scene treatment and then rapid transportation to a hospital. This role has been evolving in recent years as EMS agencies become more involved, not only in disaster preparation and response but also in community health. One agency, for example, instituted a program that reduced the county pediatric drowning rate by 50%. EMS agencies nationwide are becoming more involved in a variety of community health initiatives.

The National Highway Traffic Safety Administration (NHTSA) estimated that there were almost 20,000 EMS agencies in the United States in 2011. They examined almost 16,000 of them and found the operators were 40% fire departments, 25% private (nonhospital), 21% government (nonfire), 6% hospital based, and 1% tribal.

Maguire found an estimated 900,000 EMS workers in the United States; approximately 175,000 are full-time workers and 154,000 are paramedics. NHTSA found a similar number of personnel. NHTSA noted that volunteers provide much of the nation’s EMS and that there are over 40 different levels of prehospital providers in the United States. However, most EMS workers can be divided into two primary job classifications: basic life support personnel, such as EMTs, and advanced life support personnel, such as paramedics. Training requirements for these personnel vary by state, but in general, EMTs have a few hundred hours of training and paramedics have over a thousand hours above the EMT level. Protocols vary by state and local jurisdiction.

On a day-to-day basis, the risks faced by EMS workers include musculoskeletal injuries from carrying patients, assaults, needlesticks, and transportation-related injuries (e.g., from ambulance collisions, helicopter crashes, and by being struck by moving vehicles on the scene of a call). The EMS worker may have to carry a heavy patient down (or up) multiple flights of stairs or over slippery surfaces. EMS workers respond to calls in areas that have high crime rates and enter homes where the occupants are under great stress. The risk of needlestick injury may be increased when patients require immediate treatment in areas with poor lighting or in the back of a moving ambulance. Transportation incidents have been shown to cause the largest proportion of fatal injuries; they also account for many of the most serious nonfatal injuries.

Psychological stress may be a significant risk factor for EMS personnel, but the short- and long-term effects are not yet well understood. Nor is it known how EMS work may affect chronic conditions. Anecdotal information indicates that EMS workers tend to be young and have a high turnover rate. Therefore, there are no data on how EMS work may affect the workers’ risk of cardiovascular disease, cancer, or other conditions. In addition, little is known about the general health of the EMS workforce. Although police and firefighting agencies typically have strenuous physical standards and requirements for recruitment and continued employment, EMS agencies may have few, if any, such policies.

The availability of PPE is believed to vary widely by agency and jurisdiction. Although all EMS workers likely have ready access to surgical gloves and masks, anecdotal information suggests that many workers do not have access to helmets, rescue gloves, turnout gear, or heavy boots. This paucity of resources may exacerbate the risks faced by EMS workers during disasters.

Smith et al. found that paramedics may be reluctant to respond to a disaster if insufficiently prepared. Specialized training may double the responder’s willingness to respond. Factors that may contribute to increased occupational health risks among EMS workers during disasters include inadequate disaster-related training, lack of disaster preparation among EMS supervisors, poor coordination and communication with other public safety personnel, and inadequate equipment.

Little is known about the specific occupational health effects of disaster responses and operations on EMS workers, but this occupation is becoming more widely recognized as having among the highest rates of nonfatal injuries and illnesses on a day-to-day basis. It is reasonable to presume that such workers would be at even greater risk of injury during a disaster event.

Secondary Responders and Skilled Support Personnel

Two other categories of workers who are often deployed early in disaster response have been termed “secondary responders” and “skilled support personnel.” Secondary responders include a broad range of workers, including certain emergency public health and medical personnel, HazMat personnel, crime scene technicians, urban search and rescue personnel, mortuary personnel, radiation safety experts, structural engineers, construction workers, and others who may be involved in all aspects of the disaster response. Skilled support personnel are defined in the HAZWOPER standard as workers who are operators of certain heavy equipment, such as hoisting equipment and cranes, earth moving, or digging equipment, and who may also be exposed to hazards on site.

Although there are few studies of the exposures or health consequences experienced by secondary responders and skilled support personnel in a disaster, experience suggests they may be at risk for significant exposures, particularly because in some cases these workers receive less training and have less access to PPE than first responders. Workers involved in post-Hurricane Katrina restoration in New Orleans, for example, showed nonsignificant but elevated prevalence rate ratios of new onset asthma and pneumonia, and significantly elevated prevalence rate ratios of sinus symptoms, fever, and cough.

The WTC attack of 2001 can provide some insight into the risks faced by EMS and other emergency personnel during large-scale disasters. The hundreds of occupational fatalities following the attacks of September 11, 2001, have been well documented. Berríos-Torres et al. describe the WTC rescue workers’ nonfatal injuries and illnesses during the months of September and October 2001. Of the over 5000 incidents, the most prevalent case types were 19% musculoskeletal, 16% respiratory, and 13% eye. Fifty-two of the workers were admitted to hospital.

In summary, little is currently known about the specific risks faced by emergency services personnel during disasters. Research to identify these risks is critical so that effective interventions can be developed and tested. It is also critical that these workers receive adequate training and real-life drills prior to a disaster; such training must include safety awareness and safety preparation, including the use of PPE. Finally, personnel must participate in post-event medical evaluations, counseling, and surveillance activities so that long-term effects can be minimized.