Discussion

Most emergency response activities require awkward positioning and significant exertion, increasing the likelihood of injury as well as the need for above-average functional movement. Moore-Merrell et al16 suggested that on-duty injuries were likely to be the result of multiple contributory factors acting in concert with each other; however, no known studies of the fire service have provided a comprehensive description of the hazards and risks of operational responsibilities. While most studies related to the fire service have focused attention on the hazards and injuries during fireground operations, findings from the current study indicate that the largest percentage of injuries result from participation in some form of mandatory physical exercise during one's shift. These injuries occurred at twice the frequency of the next highest job task (ie, patient transport).

The purpose of physical exercise is to prepare one for their job and to condition a person to perform those job tasks with the utmost amount of efficiency, so that injuries are prevented. Therefore, it is somewhat of a paradox that physical exercise, which aims to prevent injuries (and other adverse health outcomes), is actually the most frequent cause of injury. The role that physical exercise plays in the occurrence and severity of injury has not been well documented in the emergency services. Exploring the root causes of these events and the manner in which physical exercise is performed, monitored and evaluated should be of greater emphasis within the fire service. The types of exercise practised by TFD include a wide range of activities (eg, jogging, basketball, circuit training, olympic lifting, metabolic conditioning, interval training, etc.), and vary in exercise programming structure and management. As supported by Barklage,19 fire departments should institute, promote and maintain a comprehensive fitness and performance programmes to ensure opportunities for maintaining the proper level of fitness necessary to complete the myriad of physical job tasks performed by ESE, and thereby decreasing the potential for acute and cumulative injuries. There are also obvious benefits to comprehensive fitness programmes, most notably the potential prevention of cardiovascular disease, which as mentioned earlier is the leading cause of line-of-duty deaths in the fire service. The National Fire Protection Association standard 1583 (standard on health-related fitness programmes for fire department members) provides relevant policies governing this aspect of work.

In addition to physical exercise, injuries were frequent during patient transport, training drills and fireground operations. Nearly 85% of emergency dispatches are in response to some type of medical issue(s), representing the most frequently performed activity by fire service personnel in TFD; whereas the most frequently trained activity understandably focuses on fireground operations, as this environment typically involved the most variability and the greatest number of hazards that pose a threat to life. Patient transport research has predominantly focused on the risk and consequences of ambulance crashes, in addition to assaults, gurney design and the ergonomic lifting and transfer of patients .20–27 Fireground research is often performed in training and drilling settings and has focused on individual issues such as heat stress, lung injury, noise, chemical and thermal hazards, slips/trips/falls and overexertion during tactical and overhaul operations.7 ,28–32 A comparison with previous research findings is not possible, as the job operations described in the current study are broadly defined and lack the level of specificity with regard to the hazards and job tasks/activities (eg, noise, patient lifting, bench press), that is often presented in other research. How operations are defined is important and will dictate the activities and job tasks undertaken, and therefore the potential hazards. For example, patient transport may be defined as simply the physical lifting and lateral transfer of a patient, or encompass the entire process from call dispatch to release of the patient at a definitive care facility. The extent of detail will depend on the individual department.

From 2004 to 2009, the annual incidence rate of injury in TFD ranged between 13.5 and 21.5 injuries per 100 employees, compared with the 2009 estimated national incidence rate of 6.8 injuries per 100 firefighters.9 ,10 It is conceivable that the increased injury rate seen in TFD is a reflection of their reporting and tendency to document all OSHA and non-OSHA reportable injuries. Injuries are reported in the TFD for purposes of documentation, accountability and tracking of potential injury progression. While this practice makes logical sense given the nature of working 24-h shifts and encountering multiple hazards during that time, it does, however, lead to an increase in the proportion of minor injuries reported. This may also explain why a well-accepted method for scoring injury severity, the AIS, did not provide much added detail on the nature of injuries in this population of ESE, because an overwhelming majority of injuries were minor in severity. In attempting to describe injury severity better in this population, identifying an appropriate metric proved challenging. The use of a trauma-based scale (ie, AIS) to measure all injuries in this setting did not represent the types of injuries well. When developing the minor injury severity scale for child injuries, Peterson et al33 noted the lack of an available scale or widely accepted method to measure the severity of minor injuries. An evaluation of functional capacity loss was considered to be a useful alternative measure for this population. The classification scheme from the FCI appears to match the general characteristics of injuries in this population well. However, given the median time loss was 6 days, FCI may not accurately measure the short-term (or acute) loss of function described in this injury study as FCI reflects the likely extent of functional limitation or reduced capacity 1 year post-injury.34 ,35

Thirty per cent of all injuries were noted to have resulted in lost time. Patient transport operations produced the greatest proportion of lost time injuries, consisting mostly of back sprains/strains (60.0%). In most occupational settings, a lost time injury is designated when the individual misses the following shift of work from when the injury occurred. Against conventional thinking, approximately half (55.2%) of the moderate injuries—comprised primarily of fractures and dislocations—were classified as having no lost time. Upon further examination, an injury was classified as lost time only in situations when the employee was not performing any department-related duties (including regular job tasks or light duty assignments), and was compensated (eg, workers' compensation). Therefore, the lost time designation could be considered more of an indicator of cost than as a measure of severity; however, this observation requires further study.

Results from evaluating AIS, FCI and lost time indicate that a more relevant measure of severity is needed for this occupational population of ESE. While the vast majority of injuries can be considered minor using a trauma-based scale, the acute loss of function can be significant. When evaluated over the span of a career, these injuries have the potential to accumulate and result in some loss of function towards the end of one's career. This is supported by the 45% of repeated injuries identified in this study's 6-year time period. In theory, a combination of an ordinal scaling system based on acute functional loss, matched to a true accounting of time loss from normal job activities, could provide an improved indication of severity to the individual, and thus the department.

This analysis was limited by a lack of detail provided by the injury database. Improvements to the description of injury events can be made by including standardised metrics for specific activity performed at the time of injury, the individual's condition before injury, equipment used, known causes, objects and equipment, or other factors (eg, environmental conditions). In order to improve any assessment of severity or functional loss, improved surveillance systems are needed that incorporate standardised metrics for injury and illness. As described by Reason,36 one of the primary steps in establishing a strong safety culture in an organisation is to improve on its reporting culture, which would enhance the ability to detail circumstances at the time of injury. The National Fire Incident Reporting System presents an excellent resource and template for departments to adopt standardised reporting structure and details.37

The at-risk exposure time is another area of study requiring further exploration. Time spent on-shift performing the job tasks described in this study has not been assessed. Evaluating the time spent performing these activities (ie, exposure time), and the environments in which they occur, would improve hazard profiles and generate a more accurate estimate of injury risk. By improving the reporting system and estimates of exposure time, the identification and characterisation of risks would occur more efficiently so that the development and application of relevant resources (ie, controls) can be implemented to mitigate potential hazard effects in the future.

This study has demonstrated that the events associated with injury among ESE occur well beyond that of the fireground. Due to the number and variation of emergency situations ESE are responsible for responding to, focused efforts should be made to identify and address the injury risks encountered during physical exercise, patient transport and training activities, in addition to the existing focus on fireground hazards. Furthermore, there is a clear need to evaluate the structure and management of physical exercise in the fire service. While most studies indicate the need for improved fitness (eg, cardiovascular health and functional mobility) in order to carry out response activities, efforts should also be concentrated on providing these men and women with improved resources and structure to maintain fitness levels and training-based skills without exposing themselves to injury in those processes.

Ongoing efforts of this research are focused on characterising the risks of injury throughout the processes of patient transport, fireground operations and physical exercise. The identification and implementation of prevention control strategies are being led by a partnership between the TFD workforce and project researchers. Intervention effectiveness will be assessed by process evaluation techniques and a comparison of overall injury rates and rates specific to each operation.