The Three-Legged Stool

Addressing preventable and modifiable risk factors

As a 28-year veteran of the Broward County (FL) Department of Fire Rescue, I have learned that both personal responsibility and leadership commitment to occupational health are of the utmost importance. I have also had the privilege of serving as a decade-long member of the International Association of Fire Chief’s Safety, Health, and Survival Section. We are all keenly aware that firefighting and public safety comes with inherent risks. However, many of the occupational threats inherent to our profession are preventable with organizational and independent actions to address our preventable and modifiable risk factors.

I have coined our greatest modifiable risk as the fire service “three-legged stool” that each of our members sits on during their entire career and, in many cases, into their post career and retirement years. (Image by Pixabay.)

I have coined our greatest modifiable risk as the fire service “three-legged stool” that each of our members sits on during their entire career and, in many cases, into their post career and retirement years. The three legs of the stool are cardiovascular health and risks, cancer occupational exposures and threats, and behavioral health risks. It is incumbent on each one of us to advocate within our departments that appropriate mitigation strategies are in place to minimize our health, safety, and survival threats and risk.

Key is the importance of regular and firefighter appropriate medical screening and physicals/wellness exams. The International Association of Fire Chiefs and its Safety, Health, and Survival Section, through an Assistance to Firefighters Grant award, developed A Healthcare Provider’s Guide to the Examination of Firefighters. Early appropriate screening is an essential step in protecting our firefighters from falling victim to one of the “three deadly fire service stool legs.” The guide can be downloaded free of charge at

Cardiovascular: The significant cardiovascular demands of firefighting have a connection to acute cardiac events accounting for 45 percent of deaths among on-duty firefighters, in contrast to 15 percent of deaths in conventional occupations. Myocardial infarction or heart attack is the leading cause of death in firefighters, and this occurs almost exclusively with susceptible firefighters with underlying cardiovascular disease or modifiable risk factors such as high cholesterol, obesity, elevated blood sugars, and hypertension. Research work has also implicated high heat stress and physiological changes that may also trigger cardiac events.

Cancer: We have learned that our chronic exposure to heat, smoke, and toxic flame retardants through inhalation, ingestion, and skin absorption elevates our occupational risks of cancer. In fact, the largest study conducted to date by the National Institute for Occupational Safety and Health examined 30,000 firefighters in three distinct geographical areas of the country. This particular study demonstrated that firefighters exhibited higher rates of digestive, oral, respiratory, and urinary cancers. Many preventive strategies have evolved and continue to do so based on research on decontamination, equipment and personal protective equipment changes and cleaning recommendations, apparatus design, bay and station design, air filtering systems, and beyond. However, we also know that early screenings mean in many cases early stage detection and successful outcomes. Hence, when we are sitting on this seat of this “leg” of the stool, early annual screenings save lives!

Behavioral health: We know from the existing body of research that firefighters are at greater risk of occupationally induced behavioral health issues from elevated stress and repeated exposures to traumatic events, including elevated rates of sleep disorders, stress, post-traumatic stress disorders, alcohol and substance abuse, depression, and suicide ideation and suicide than compared to general population controls. It is essential that support mechanisms are in place to address these behavioral health issues, such as employee assistance programs, behavioral health awareness programs, and peer support programs and training. Annual preventive screenings play a major role in the early detection of behavioral health disorders and are a crucial step in the identification of early symptoms and warning signs and addressing those symptoms and signs through treatment and support pathways.

The challenge for each of us in the fire service is to assess and reassess whether we are addressing each “leg” of the stool to ensure we are doing everything we can to guarantee “Everyone Goes Home!”

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