Cancer… PTSD…Dehydration…Lack of Physical Fitness…Vehicle Accidents. All of these safety concerns have been recognized as very real occupational hazards in the fire service. Great strides have been made to correct deficiencies in these areas in the past few years. A true culture change in regards to safety has taken place in a relatively short period of time. But what if there was another danger that we have ignored for too long? What if that hazard has been the number one issue for athletes for over a decade? What if the fire service has ignored the concussion crisis? After all, thousands of firefighter head injuries are reported every year.
Concussions were never on my radar as something that could affect my career or my long term health. I grew up in a firehouse. My father recently retired as a 30 year veteran and he volunteered for many years before that. My story was similar. I began my firefighting career volunteering in 1999 and I was hired by Henrico County (VA) Division of Fire in January of 2003. Through all these years, never once did I hear any firehouse conversations regarding concussions on the fireground…much less during any formal training.
In November of 2015, while at our drill school, a 35 foot ladder fell on me as it was being lowered to the ground. It hit my helmet and threw me to the asphalt where I smacked my head again. I didn’t know it at the time, but in a split second my career and my life would take a drastic change. Sure, I had some obvious injuries that needed to be taken care of. A bloody nose, an abrasion to my forehead, and an elbow that became swollen to the size of a softball took most of my attention. Little did I know some other symptoms I was having should have been more alarming. Immediately after being hit I saw stars and had double vision. A headache crept in and stayed.
Looking back on it; I have no recollection of getting to the hospital. Apparently there was nothing I was doing to put up a red flag to my crew that I had a potentially career ending injury. Autopilot took over. I was diagnosed with a concussion in the emergency department and sent to an orthopedic for my elbow which healed just fine in a few weeks. However, the concussion symptoms not only lingered, they got much worse over the next few months. Even with the help of a neurologist, I couldn’t sleep. I was dizzy and fell often. Chronic fatigue was a huge problem. I got lost in places I’ve been hundreds of times and the stars I was seeing and the double vision just wouldn’t go away. Light and sound became painful. When my heart rate increased the room would spin. I developed a rage reaction to the smallest inconvenience. Eventually, we would discover about 25% of my vision was gone.
The mounting frustration over not getting back to normal sent me on a mission to find out what I had done to myself. After some research on concussions I found that there was a ton of information that I didn’t know about them and I couldn’t help but think of how it applied to the fire service. I’m an athlete. I take that seriously. I’m required to train like one. My officers preach that I am a “fire athlete” or “occupational athlete.” My physical capabilities are tested every year. I wear a helmet. If I am injured, I can’t play.
I started with Google searches and YouTube videos. One compelling series on concussion that I suggest everyone watch is called League of Denial: The NFL’s Concussion Crisis by Frontline. There is a ton of eye opening information in that series. From there I watched a documentary called Head Games which gave a more in-depth look at the consequences of sports related concussions. As timing would have it, a month after my injury the big movie Concussion (starring Will Smith) was released in theaters.
When I was able to return to light-duty I requested to study this further. Our Health and Safety Officer obliged and we discussed his on-duty Traumatic Brain Injury that occurred a few years back. I learned there was another firefighter in our department that was out with a concussion as well. As time went on yet another firefighter told me that ten years ago he was out of work for six months for a concussion. I thought back to when I was involved in a serious motor vehicle accident while assigned to a heavy rescue unit. My helmet was damaged and my shoulder required multiple surgeries to repair. There was also the time I hit my head on the door of the engine pulling my bunker gear up and saw stars for a few days. I never reported it because the symptoms eventually subsided. This got me thinking not just if concussions are a problem in the fire service, but… how big of a problem are concussions in the fire service?
I started a search to find how many concussions were reported in the fire service. Although concussions are not specifically recorded, according to NFIRS up to 15% of all firefighter injuries are head injuries. That’s about 12,160 firefighter head injuries between 2006 and 2008…a whopping average of 4,053 a year. As a comparison, the NFL reported 244 concussions in 2016. The NCAA Injury Surveillance Center reports an average of 1,364 football concussions per year. The concussion crisis doesn’t stop with sports. In fact, the U.S. military is referring to “mild” Traumatic Brain Injury or mTBI as the signature wound of the Iraq and Afghanistan Wars. A 2017 JAMA Neurology study found considerable decline in service members five years post injury. Why hasn’t the fire service taken a deeper look?
The scary truth is that concussions are vastly underreported. The thousands of firefighters who reported a head injury could be just a fraction of those who actually sustained one. In fact, according to the Concussion Legacy Foundation, only one in six concussions are reported. There are many reasons why people do not report them. I believe the main reason is ignorance. People are just not educated about the facts. I was one of those who just didn’t know what I needed to.
The culture of wanting to “stay in the game” is another huge problem. It’s the same tough guy attitude that got firefighters killed for not wearing seatbelts and facemasks. It’s the same tough guy attitude that makes wearing cancerous dirty gear seem cool. It’s the same attitude that prevents athletes from admitting they have a head injury.
It’s not easy to diagnose a concussion and that’s a huge problem. Symptoms can be elusive and evolve. It’s an invisible injury. There are no casts, no crutches, and no slings to draw attention to the fact that someone has a concussion. This often is the reason a coach or in our case an officer would miss a concussion in his/her crew. Training to better understand the signs and symptoms of concussion is vital to diagnosing and treating them properly. Currently, most people when asked about signs and symptoms of concussion might say LOC, nausea, vomiting, or seeing stars. However, there are over twenty symptoms after a concussion that can take hours or days to develop. Physical, cognitive, emotional, and sleep changes are clues to concussion symptoms that must be reported. Taking a bad bump on Monday can be the reason you can’t sleep on Thursday. Symptoms like balance problems, irritability, sensitivity to light or sound are signs your brain’s functions are not working properly. We need to know this stuff.
One big obstacle to correct the problem of under diagnosing concussions isn’t the fault of athletes, coaches, or the fire service. Currently, there is no universal definition of concussion. This can lead to further confusion. For the purpose of trying to get everyone on the same page I will use the Concussion Legacy Foundation’s definition. After all, they are the education and advocacy branch of the brain bank that has studied the NFL players that sparked a national conversation. This is their definition;
“A concussion is a serious injury to the brain resulting from the rapid acceleration or deceleration of brain tissue within the skull. Rapid movement causes brain tissue to change shape, which can stretch and damage brain cells. This damage also causes chemical and metabolic changes within the brain cells, making it difficult for cells to function and communicate.”
A brain is the consistency of Jell-O and floats in fluid inside the skull. This is the key to understanding the mechanism of injury during a concussive blow. A concussion is an acceleration/deceleration injury. One big concussion myth is that helmets prevent concussions. They do a good job of preventing skull fractures and penetrating injury however; the brain can twist, stretch, and strike the inside of the skull tearing connections during acceleration and deceleration. Just because a firefighter is wearing a helmet doesn’t mean he/she can’t have a concussion.
It is important to debunk some other myths surrounding concussions as well. Loss of consciousness is not required to diagnose a concussion. In fact, the vast majority of concussions do not have any LOC. Another myth is that only a blow to the head can cause a concussion. Whiplash, a strong hit to the chest or back, and being near an explosion can cause a concussion. Remember… acceleration and deceleration.
Concussions are not seen on CT or MRI scans. A “clear” CT is a good thing, but it doesn’t rule out problems. These tests are good for finding structural damage and bleeding but not the microscopic damage that is done on a cellular level. They also can’t test function so keep that in mind. Some providers mistake the Glasgow Coma Scale as a diagnosis tool for concussion. GCS determines the severity of coma. Obviously, with a low GCS there are problems; but someone with a perfect GCS can still have a concussion.
One of the biggest myths about concussions is that if symptoms have gone away it is safe to return to normal activity the same day. For example, Firefighter Smith has concussion symptoms after slipping on ice while on an EMS call. He saw stars and had double vision for a few minutes but now he says he is no longer symptomatic. Firefighter Smith should not return to duty for at least 24 hours. The research is clear about this. In sports, returning to play is not advised the same day a player has concussion symptoms.
Immediately after a concussion the brain is extremely vulnerable. A concussion causes neurons to release a massive amount of neurotransmitters that interferes with cell communications. Any further physical stress or even a cognitive load can cause further cell death and create permanent brain damage. Rest is critical post-concussion. Pulling a firefighter from duty that you suspect has a concussion can give them the best chance to heal.
When properly managed, the majority of concussion symptoms will resolve within a couple of weeks. However, over-exertion of brain cells during recovery can cause symptoms to persist for months or even years. A significant percentage (estimates vary between 10% and 30%) of concussion patients suffer from extended recovery, known as Post Concussion Syndrome.
A rare but serious condition called Second Impact Syndrome can be avoided with rest. Second Impact Syndrome kills approximately six high school football players a year. Typically, it involves an athlete suffering post-concussive symptoms following a head injury. If, within several weeks, the athlete returns to play and sustains a second head injury, diffuse cerebral swelling, brain herniation, and death can occur. SIS can occur with any two events involving head trauma. In 2010, a Norfolk, Virginia Police Recruit died from Second Impact Syndrome. Resting after a concussion can prevent a tragedy like this.
Another scary long term consequence of concussion is depression and suicide. Studies suggest that people diagnosed with one concussion in their lifetime are three times more likely to commit suicide than those people with no concussion history. PTSD is already a hot topic in the fire service. It is interesting to note that PTSD and concussion symptoms have a ton of overlap. Cognitive dysfunction, disorientation, sleep disturbances, anxiety, depression, fatigue, and sensory impairments are all symptoms that are seen in both. Not every PTSD case is really a hidden TBI. Being a witness to or participant in traumatic events is almost a job requirement for us. However, the symptoms are so similar it is worth further investigation because a long forgotten blow to the head can be misdiagnosed as anything from PTSD, ADHD, or bipolar disorder.
It’s common knowledge that banging your head is bad for you. Back in the 1920’s, during the golden age of boxing, the term “Dementia Pugilistica” or “Punch-Drunk” was first described when witnessing the mental decline in boxers had post fight. In 2005, a pathologist named Bennet Omalu published the first evidence of this trauma related brain disease in former Pittsburg Steeler Mike Webster. Omalu called his discovery Chronic Traumatic Encephalopathy, or CTE for short. The discovery of CTE launched concussions onto the front page of newspapers and into commentary booth. Since then, 110 out of 111 former NFL players who have donated their brain to be studied after death have been diagnosed with CTE. Think about that number for a minute. Nearly 100% of NFL players that were studied had trauma related brain disease. These studies include players at every position from quarterback to place-kicker. So what is CTE?
Concussions can cause an abnormal build-up of a protein called tau which slowly kills brain cells. Once started, these changes in the brain continue to progress even after exposure to brain trauma has ended. This process can lay dormant for years. Symptoms of CTE include memory loss, confusion, impaired judgment, paranoia, impulse control problems, aggression, depression, new onset drug use, suicidal thoughts and actions, and eventually progressive dementia. CTE is a progressive degenerative disease of the brain found in athletes, military veterans, and others with a history of brain trauma. CTE is not Alzheimer’s and can only be diagnosed after death. The current thought is that the more concussions a person receives, the higher the risk for CTE. Sub-concussive blows (hits to the head that do not cause symptoms) are also thought to be a contributing factor. They may be an even bigger risk than blows to the head that do cause symptoms. This is why it is important to treat concussions as an exposure to this disease like we do with Haz-Mat incidents and cancer preventative measures.
Football and the military are not the only areas that have an issue with concussions. Dale Earnhardt Jr., arguably NASCAR’s most popular driver, sat out half of a season to recover from concussions. Professional wrestler Chris Benoit killed his wife, son, and himself and was later found to have CTE. X-Games superstar BMX rider Dave Mirra, who committed suicide, also had CTE. Boxing, soccer, rugby, baseball, basketball, and hockey have all had confirmed cases of CTE. Domestic violence victims and individuals with developmental disorders who engaged in head banging behaviors as well. The fire service should take note of these new findings and even consider firefighters past athletic experiences.
So now that we have identified the problem, we need to look for solutions.
The first and greatest step we can take is education. Training is the key. All major sports from the professional level to school athletics are required to review concussion information on an annual basis. Why not us? If this information is given to firefighters nationwide then we can have the conversations that can begin to address the issue.
A top down approach is needed. Chief Officers must make it clear that they expect their crew to report if they see signs of concussion in one of their crew members. This is informed consent. Firefighters deserve to know the risks of their jobs. It is the officer’s job to make sure their firefighters are educated on those risks and how to avoid them. Officers need to teach their firefighters that ignoring symptoms of concussions is dangerous. Anytime symptoms are observed or reported action should be taken to remove the firefighter from a situation where they can be exposed to another hit or make a mistake in the field because they are confused.
On the fireground, special attention needs to be given to events that give a high probability of concussion. Firefighters involved in motor vehicle accidents, falls, collapse, or that are near an explosion need to be immediately pulled from duty and evaluated. We need to advocate self reporting and the “tough guy” attitude needs to be left behind.
One other solution to the concussion problem in the fire service is how we treat them. Worker’s Compensation covers career departments. But anyone that has gone through that process can tell you it isn’t an easy road. The IAFF/IAFC Joint Wellness Fitness Initiative states:
“The fire department must take the lead in ensuring that uniformed personnel are properly rehabilitated prior to returning to full duty. Informed decisions should be made by clinicians familiar with fire fighting job requirements”…
“In short, the fire department must control the process and provide the necessary input to drive this process, and labor must support the rehabilitation process from beginning to end.”
So the Emergency Department diagnoses your firefighter with a concussion… Now what? Good question. A 2017 study examined current concussion care and practices in the New England area. The study surveyed 168 Emergency Departments. The study found “significant variability in concussion care practices and the application of evidence-based clinical practice guidelines for the evaluation and management of concussion in EDs throughout New England.” 97% of ER providers discussed with patients they may have difficulty thinking and remembering. However…discharge instructions, specialist referrals, and recommendations as when to return to normal activities varied greatly.
My suggestion is for fire departments to take the IAFF and IAFC’s advice and steer concussed firefighters to an appropriate concussion rehab clinic. Concussion rehab clinics have a multidisciplinary approach with neurologists, neurosurgeons, neuropsychologists, certified athletic trainers, vestibular therapists, radiologists, neuro-ophthalmologists, and researchers all under one roof. This may not be easy with all the red tape involved with Worker’s Compensation; however it is a clear goal that can be addressed at a management level.
Baseline Concussion Testing has become a standard for sports with high risk for concussion. A comprehensive approach to concussion management starts before the injury actually occurs. Before the season begins a test is given to athletes to measure reaction time, memory capacity, speed of mental processing, and executive functioning of the brain. The athlete will then retake the test after a concussion to compare the results. There are many different tests that are used and can easily be included into a yearly physical. These tests are relatively inexpensive and can be quite beneficial. Some of these tests are even mobile and can be installed on a tablet to give in the field post-concussion. An added bonus to annual baseline testing is that just by being tested firefighters will be reminded about concussions.
Establishing an SOG for firefighter concussion education and a treatment plan is the ultimate goal to ensure consistency and improvements at a company level. An important thing to consider is that no concussion protocol is going to be 100% effective. The NFL and many other high profile arenas have their policies on full display. It doesn’t take long to notice these protocols are flawed. We can’t let that deter us. Improving the health and safety of the fire service should be the highest priority no matter the size of the department or if firefighters are career or volunteer. Perfection can’t be the enemy of progress. Thousands of firefighters have sustained head injuries on duty and thousands more will follow. We owe it to them and their families to try to find solutions.
Mat Blankenship grew up in the Ashland (VA) Volunteer Fire Company where his father served with many other family members. In 1999, Mat officially began his fire service career by joining the AVFC. There he served as Historian, Vice-President, and Fire Prevention Officer, and was voted “Firefighter of the Year” in 2001. In 2003, he was hired by Henrico (VA) County Division of Fire where he has been assigned to Engine 6, Truck 6, Engine 14 and Squad 13. Mat can be reached at BLA01@henrico.us or on Facebook at Firefighter Concussion Protocol.