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Patient Care

Resuscitation on the Fireground: Prevention, Recognition and Response


Each year around 100 firefighters die in the line of duty, with nearly half of those deaths attributed to cardiac events.1 Even among firefighters under 45 years old, approximately one in five deaths are due to cardiovascular emergencies.2 Firefighters perform strenuous work in heavy gear while being subjected to extreme environments. The cardiovascular workload encountered is not unlike running a marathon, except in a situation where the ambient temperature may exceed 250ºF. Unfortunately, firefighters are simply normal humans thrust into a superhuman task.

The significant cardiovascular and thermal strain experienced during firefighting alters myocardial function and blood chemistry, placing firefighters at roughly 10 to 100 times the risk of suffering a cardiovascular emergency.3 If a firefighter collapses in cardiac arrest during fire ground operations, response can be complicated and delayed by the presence of full turnout gear with a SCBA and facemask.

Before stepping onto the fire ground alterations in myocardial function are seen. Studies of healthy subjects have shown that during the alarm response—such as when firefighters are noxiously aroused by their pagers—changes in myocardial repolarization occur with T-wave inversions on the ECG.4 After arriving, hazardous levels of chemicals—such as hydrogen cyanide—have even been recorded outside structures on fire where firefighters routinely do not use their SCBA.5,6

Once actively engaged in firefighting, significant plasma shifts occur combined with increased platelet count and aggregability.7,8 To complicate matters, firefighters often bring significant comorbidities and lifestyle risks to the job.9,10 Given all of these factors it is easy to see why cardiovascular events alone are as prevalent as death from traumatic injury.

Clear evidence exists for the effective treatment of out-of-hospital cardiac arrest (OHCA). A comprehensive resuscitation bundle, including early continuous chest compressions, ensures that good neurological outcome following cardiac arrest is not only possible but probable. However, if a firefighter suffers sudden cardiac arrest while in full turnout gear and SCBA, providers must overcome this access issue to enable early hands on the chest and continuous compressions.

Captain Tom Bouthillet, from Hilton Head Island Fire and Rescue, previously raised the concern of the prolonged no-flow time while removing the gear from an unresponsive firefighter.11 This call to action led to a novel approach known as Firefighter Down: CPR (FD-CPR). Early attempts at FD-CPR were refined through careful practice and analysis of what did and did not work. In its final form, FD-CPR provides a clear path to manage the removal of turnout gear, including a facemask and SCBA, from an unresponsive firefighter (See Table 1).

The first rescuer stabilizes the downed firefighter with their legs on either side of the SCBA (see Figure 1). This allows a second rescuer to remove immediate obstructions from the front of the downed firefighter’s coat and begin chest compressions utilizing the SCBA as a make-shift CPR board (see Figure 2). The rescuer at the head removes the downed firefighter’s helmet, facemask and hood while additional rescuers begin working open the turnout coat and removing the downed firefighter’s hands from any wristlets (see Figure 3). Once the coat is open, the hands are free, and the facemask and hood have been removed, the additional rescuers coordinate pulling the downed firefighter free of their coat and SCBA (see Figure 4). At this step EMS and the rescuers should initiate a comprehensive resuscitation bundle targeting the likely etiology of the cardiac arrest. If practiced, this entire process takes no longer than 15 seconds and minimizes no-flow time once the downed firefighter has been rescued.

FD-CPR has been adopted by fire departments across the world owing to its simple and repeatable steps. Departments who include FD-CPR in their training are encouraged to practice the steps and to make any necessary modifications due to their equipment. These best practices can then be shared via social media or the FD-CPR website to help other departments improve this technique.12 FD-CPR plays an integral role in bridging Rapid Intervention Teams with EMS care of downed firefighters and may help to improve survival to discharge for sudden cardiac arrest on the fire ground.

10 Steps to FD-CPR

The following 10-step technique became our FD-CPR approach; however, we found that many steps can be performed simultaneously, reducing the time to doff the firefighter to 30 seconds or less, all while maintaining high-quality compressions.

Step 1:

  • Rescuer 1: Drag the downed firefighter to a safe location to initiate care. Rescuer 1 should drag the firefighter from behind, drop to the ground and position the SCBA bottle between Rescuer 1 legs.
  • Rescuer 1 legs will serve to stabilize the SCBA so that it can be used as a CPR platform.

Step 2:

  • Rescuer 2: Should pop open the chest clip of the SCBA if applicable and initiate high-quality compressions through the turnout gear jacket.
  • Rescuer 2 should be a “fresh” firefighter (i.e., the engineer or a member of RIT that has not yet performed strenuous firefighting activity). The quality of compressions are paramount, and under this circumstance, fatigue and a decline in compression quality will be rapid.

Step 3:

  • Rescuer 1: If the SCBA mask is still in place, open the SCBA bypass valve. This step can also be performed by Rescuer 2 quickly.
  • This step may be omitted, but can be used to add passive oxygenation while chest compressions are ongoing. This step may also assist in understanding why the firefighter went down. If there is air remaining, it is unlikely the firefighter suffered a hypoxic arrest.

(Steps 4–8 should be performed in a coordinated method but simultaneously to the best of the ability of the rescuers. Do not interfere with compressions. Depending on the style of gear your department carries, modifications may need to be made.)

Step 4:

  • Rescuer 1: Remove helmet, mask and hood.

Step 5:

  • Rescuer 3: Position yourself at the waist and start to unbuckle the turnout gear jacket from the bottom up.

Step 6:

  • Rescuer 1: Loosen shoulder straps of the SCBA and position the arms of the down firefighter above his/her head.

Step 7:

  •  Rescuer 1 and Rescuer 3: Work the zipper (or buckles) of the turnout gear jacket open. Do not interfere with compressions.

Step 8:

  • This is a make or break step. Rescuer 1 needs to grasp the turnout gear jacket and the SCBA shoulder straps of the down firefighter firmly. Prepare for the “pull down.” Rescuer 1, who is at the head of the down firefighter, will give the final command to perform the “pull down.”

Step 9:

  • Rescuer 3 and Rescuer 4: Each Rescuer needs to firmly grab one of the down firefighter legs and coordinate the “pull down” method with Rescuer 1 at the head. Rescuer 1 will give the command to perform “pull down.” Rescuer 3 and Rescuer 4 will pull the down firefighter toward his/her feet and out of the turnout gear jacket and SCBA.

Step 10:

  • All rescuers: Initiate a comprehensive resuscitation bundle! The first step is to continue high-quality compressions with a “fresh” person.
  • The etiology of the arrest should drive care from this point forward. For example, if the firefighter ran out of breathing air or their mask was removed or compromised, consider a hypoxic cause and treat accordingly. In that case it would be appropriate to treat for cyanide toxicity as well, provided it does not interfere with standard care.


1. NIOSH. Fire Fighter Fatality Investigation and Prevention Program.

2. Yang J, et al. Sudden cardiac death among firefighters ≤45 years of age in the United States. Am J Cardiol 2013; 112:1962–1976.

3. Smith DL, Barr DA, Kales SN. Extreme sacrifice: sudden cardiac death in the US Fire Service. Ex Phisiol Med 2013; 2:6.

4. Dweck MR, et al. Noxious arousal induces T-wave changes in healthy subjects. J Electrocardiol 2006; 39:324–330.

5. City of Columbia Fire Department. Standard Operating Guideline OPS-036: Hydrogen Cyanide Monitoring. 2010.

6. Brandt-Rauf PW, et al. Health hazards of fire-fighters: exposure assessment. B J Ind Med 1988; 45:606–612.

7. Horn GP, et al. The Effects of Fire Fighting and On-Scene Rehabilitation on Hemostasis. University of Illinois Fire Service Institute. 2010.

8. Smith DL, et al. Clotting and fibrinolytic changes after firefighting activities. Med Sci Sports Exerc 2014; 46(3):448–454.

9. CDC. Fatalities Among Volunteer and Career Firefighters—United States, 1994–2004. Morbidity and Mortality Weekly Report 2006; 55(16):453–455.

10. Ibid 2.

11. Bouthillet T. Cardiac arrest. Are you ready to save one of our own? EMS 12-Lead Blog and Podcast.

12. Watford CA, Herbert M. Firefighter Down: CPR—Prevention, Recognition, Response.

Michael  D. Herbert, BS, NRP, is a firefighter/paramedic with Leland Volunteer (NC) Fire/Rescue Department, Inc., and a clinical educator for ZOLL–Minneapolis. He has worked all sides of fire and EMS, from a tailboard rookie up to a line officer, engineer/operator, field training officer and EMS instructor. He is a two-time State of North Carolina Paramedic Competition champion, co-creator of the Firefighter Down: CPR (FD-CPR) project, an enthusiastic educator and a physiology nut.

Christopher A. Watford, BS, NRP, is a lead software engineer with Global Nuclear Fuels, a part-time paramedic with New Hanover (NC) Regional EMS, and a volunteer paramedic/EMS captain with Leland Volunteer (NC) Fire/Rescue Department, Inc. He is a senior editor with the EMS 12-Lead blog and podcast, and a two-time State of North Carolina champion paramedic. Christopher is an ECG fanatic, a devourer of research, and enjoys mixing software and medicine.


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