FRI 2023: ‘Been hit in the head lately?’

By Chief Todd J. 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 injury with severe deleterious effects (1).

Protocols have been developed to identify and appropriately respond to risks, and research in this area is blossoming. Emerging data has reinforced the risk associated with even a single acute incident and the exponentially increased dangers of repeated and untreated injuries (2). Despite this increased interest in the public setting, the fire service remains unprepared for the unique risks of head injuries on scene and their consequences off scene.

It is past time for a national effort to address this disparity.

Firefighter impact

Head injuries are common in the fire service. Firefighters are exposed to ceiling and building collapses, they must navigate through smoke-filled environments, and can impact walls and other items headfirst. Often, these injuries go unreported, as the danger of such events is currently under-recognized. Even still, 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 NFPA over a five-year period from 2015 to 2019, 11% of injuries reported were due to head injury, making it the third most common type of injury (3).

Bolstering these numbers, research has found that 76% of firefighters report at least one head injury in their lifetime (4). Some injuries are minor, yet some are more serious, directly impacting the firefighter’s brain and potentially leading to long-term consequences.

As evidenced in studies related to professional sports (e.g., NFL, NHL) as well as college and youth sports, repetitive head injuries lead to jarring of the brain and produce physical and neurologic injuries. Further, 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 injury (4). What’s more, emerging data suggest a correlation between concussion history and future musculoskeletal injury, further compounding the risk.

Despite both the frequency and severity of this type of fireground injury, little guidance exists for reporting, recording, appropriately responding to, and managing head injuries or examining potential neurologic deficits throughout a firefighter’s career. Even guidelines like NFPA 1582: Standard on Comprehensive Occupational Medical Program for Fire Departments do not directly address head injuries or lingering effects as part of ongoing incumbent medical evaluations. There have been articles in fire service trade journals (5-7) highlighting the issue, but there have yet to be any national initiatives such as awareness training, PPE design considerations, risk reduction efforts, on-scene concussion protocols, standardized reporting or return to work concussion clearance protocols.

The cost factor

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 performed (8). 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 2013 (9). 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 injuries (9-12).

Further, according to Air.org, in a retrospective claims analysis of mTBI patients over a 12-month period, mean follow-up healthcare 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) (10). Addressing root causes such as head trauma/TBI for PTSD alone has a lifetime potential healthcare system cost savings of 1.4 million per individual.

More work ahead

While research specific to firefighters is evolving, there exists several 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, limiting change.

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 all needed to decrease the long-term impact of these injuries.

Additional work in this space will expand efforts already competed related to professional athletes and the Department of Defense, furthering our work to improve the health and safety of the American fire service.

ABOUT THE AUTHOR

Chief Todd J. LeDuc, MS, CFO, FIFirE, recently retired as assistant fire chief of Broward County (Florida) Fire Rescue and joined Life Scan Wellness Centers as chief strategy officer. Chief LeDuc is also the secretary of the International Association of Fire Chief’s Safety, Health & Survival Section. He can be contacted at mailto:Todd.LeDuc@lifescanwellness.com.

References

1. Brown A, Moessner A, et al. “A Survey of Very-Long-Term Outcomes after Traumatic Brain Injury among Members of a Population-Based Incident Cohort.” J Neurotrauma. 2011;28:167-176.
2. Walker A, Chapin B, et al. “Association between single moderate to severe traumatic brain injury and long-term tauopathy in humans and preclinical animal models: a systematic narrative review of the literature.” Acta Neuropathol Commun. 2022;10(1):13.
3. Campbell R. Firefighter Injuries on the Fireground. NFPA 2021.
4. Strack J, Torres V, et al. “Psychological distress and line-of-duty head injuries in firefighters.” Occ Med. 2021;71:99-104. doi:10.1093/occmed/kqab013
5. Lavelle K. Fireground emergencies: Firefighter head injuries. EMS1. Published online 2012.
6. Blankenship M. “The Fire Service Has a Hidden Concussion Crisis.” FirefighterNation. 2017.
7. Staff. “Concussions: Assessing the Risk for Firefighters.” Fire Engineering. Published online 2018.
8. McKeithan L, Hibshman N, et al. “Sport-related concussion: evaluation, treatment, and future directions.” Med Sci. 2019;7(3):44.
9. McGinity M, Grandhi R, et al. “The impact of tackle football injuries on the American healthcare system with a neurologic focus.” PLoS ONE. 2018;13(5):e0195827.
10. Pavlov V, Thompson-Leduc P, et al. “Mild traumatic brain injury in the United States: demographics, brain imaging procedures, health-care utilization and costs.” Brain Injury. 2019.
11. Wilkins S, Shannon C, et al. “Establishment of a multidisciplinary concussion program: impact of standardization on patient care and resource utilization: clinical article.” Pediatrics. 2014;13(1):82-89.
12. Taylor A, Nigrovic L, et al. “Trends in Ambulatory Care for Children with Concussion and Minor Head Injury from Eastern Massachusetts between 2007 and 2013.” J Pediatrics. 2015;167(3):738-744.