Put aside the emotion when considering adding to a number we try to lower each year
The topic of firefighter suicides is one that gets raised once or twice a year and is full of intense but quiet emotion. Quiet because the subject of suicide is one that people do not like to discuss; intense because when it is discussed some people make the mistake of passionately identifying these deaths as part of the sacrificial duty of a firefighter and consider them worthy of recognition equal to having been killed inside a burning structure. Unfortunately, when we talk about the actual number of line of duty deaths, the fire service has a hard time keeping the facts, or data, separate from the emotion. Considering a firefighter taking his or her life as a line of duty death has many consequences that range from skewing yearly fatality data to causing deep divides among firefighters from the local level on up to our national fire service figures and organizations. The intent may be noble but the end result would be torment.
LODD and On-Duty Death
Before we discuss adding firefighter suicides we need to first understand or remind ourselves the official terminology and definition processes. Two national organizations, the United States Fire Administration (USFA) and the National Fallen Firefighters Foundation (NFFF) each have specifics that govern the identification and inclusion processes for a fallen firefighter to be considered as a line of duty death. The terms themselves are also unique and need to be understood. Many states have their own definitions and guidelines regarding the determination of firefighter fatalities, but for this article and the relation to yearly national reports, we will focus only the USFA and NFFF material.
For the USFA, “on duty” refers to being involved in operations at the scene of an emergency, fire or non-fire; responding to or returning from an incident; performing other assigned duties; and being on-call or standby, except at home or work. Firefighters who become ill performing duties and have a heart attack shortly after returning home, or at another location, may be considered as “on duty.”
For memorial purposes, the NFFF considers a line-of-duty death (LODD) as that which occurs during an activity or action where a firefighter is obligated or authorized by various rule, agreement or other law to perform as part of the fire service he or she serves, and the action is legally recognized. Documentation must be shown to provide a direct link from the incident to injury and death. In the case of deaths resulting from heart attack or stroke, proof must be presented to show the victim’s participation in emergency response or training activities within the 24-hour timeframe before the cardiovascular event.
The NFFF also identifies specific causes of deaths that exclude firefighters from memorial consideration: deaths attributed to suicide, alcohol or controlled substance abuse, and deaths resulting from the victim acting in a grossly negligent manner. There are other specifics and criteria used by both the USFA and the NFFF in determining eligibility into their respective accounts in cases such as deaths from previous years, delayed reporting or other causes of death that are individually weighed by the respective programs.
Reasons Not to Add to Our Yearly Numbers
The Fog of Suicide
The very nature of this mode of death (suicide is not a cause but one of four modes used for legal definition) gives it a stigma that makes even the best reporting of it foggy. Data the fire service relies on when reviewing firefighter fatalities in efforts to prevent more is and should remain as specific and detailed as possible. The problem with the proximal intent of suicide is that the external factors are many and develop over a period that can be seen as elongated when compared to firefighter fatalities of the line of duty or on-duty nature, even when compared to deaths involving stress/overexertion as autopsies show cause. For example, the autopsy of a firefighter who suffers a fatal cardiac event can reveal that the victim died from atherosclerotic and hypertensive cardiovascular disease. The victim’s medical history can be researched back for many years to reveal a diagnosis of hypertension and type 2 diabetes mellitus. We can further learn of this history through department medical reports and family history/details, which may include being a life-long smoker, obese and someone who did not participate in regular exercise or a healthy diet.
One could say that similar information can be taken from the autopsy of a firefighter who died as a result of suicide, and be used to support information geared toward prevention. The rub is that not every firefighter fatality has an autopsy performed. If one did for a victim of suicide, the findings of cause and mechanism of death, as well as toxicology, may not be released and if so do little to provide a strong enough resource for preventative information. It might be reported that a victim was prescribed the antidepressant Lexapro, but unlike being described a drug for lowering cholesterol, antidepressants and the treatment of depression have a far wider range of delivery, coupled with other treatments, too far to be isolated AND that is if the act of suicide can be undeniably linked to depression.
Current efforts to reduce line of duty deaths have as their support firm data derived from the fatal incidents and investigations. The fire service relies on this data to support the most reliable actions to take as a preventive of further fatalities. When a firefighter is killed in a building collapse, we are given information on the building’s construction and the actions the victim and others took prior to, during and after the collapse. Supportive information is given to reinforce lessons learned and support recommendations and best practices. The same is true when a firefighter is killed after having been ejected during an apparatus accident. Once the investigation is complete, we learn about the lack of seat belt use, vehicle speed and characteristics, the victim’s training and more. Similar definitive information, in most cases, cannot be derived from the investigation of a firefighter’s suicide. The wide range of methods of suicide and the even wider range of contributing circumstances – if proven and publicly released - make it impossible for the CDC or other related fatality prevention organizations to make any sound recommendations. Just look at the dialogue about NIOSH reports and recommendations from any fireground fatality; the debate is active and large about their usefulness.
Adding More Statistically Irrelevant Data
Each year the USFA and other national organizations issue a yearly report on firefighter fatalities. The data, which I am critical of (it needs to be broken down in greater detail), is quite broad but does a fair job in disseminating the causes of firefighter fatalities and related details. The data is broken down by agency type; duty type; causes of fatal injury; nature of fatal injury; and other categories such as time of injury and more. It should be noted at the start that the USFA already does not include in their reports fatalities that occurred when the victim became ill after going off-duty and had participated in activities that did not involve physical or mental stress. There is also no reporting of deaths due to illnesses developed over a long period of time in the same reports.
“Other” is the field in these yearly reports and current year to date information where deaths that don’t fit the specific fields under Cause of Fatal Injury, such as Stress/Overexertion; Vehicle Collision; Struck By; Collapse; Fall; Caught/Trapped; and Contact With. In 2012 Other contained four deaths: pulmonary embolism; drowning; natural causes and a cause still to be determined. In 2013 seven fatalities were listed in Other. 2014 currently has no fatalities listed in Other but does have two under Unknown. The point of understanding Other is that unless there is specific, reported follow-up on these fatalities, Other simply becomes just part of the lump sum and is useless in having any educational relevance. Now, add in suicide data as recorded and reported by the Firefighter Behavioral Alliance for this year and the past two years:
Current On-Duty Deaths per USFA: 37
Suicides per FBHA: 21
On-Duty Deaths per USFA: 107
Suicides per FBHA: 59
On-Duty Deaths per USFA: 81
Suicides per FBHA: 58
The big question the fire service will have to answer, if you count suicides as on-duty deaths, is what do we do with “Other”? We know that the exact data on firefighter suicides is grossly inaccurate and under reported, so when we add suicide we take what is already questionable data and skew it even further. If we are going to be having these honest, hard discussions, then when it comes to fatality data the first discussion we need to have is what do we do with suicides? Current information for the fire service on suicides already makes it known that, as Richard Gist, PhD. said during a 2013 conference on the subject, we just don’t know a lot about firefighter suicides.[i] A similar message is also presented in material for clinicians and chief officers from the NFFF.[ii]
Does this imply that the data will eventually be better as it is recorded? For the study of firefighter suicides, yes, but for the statistical value of yearly fatality reporting, no. Take a look at the “Other” data we have as well as the data where the victim died “several hours after shift”. What relevant training value comes from that data? How will you as a fire officer compile and present training information on health and fitness using, for example, the death of an over 60-year old volunteer who died at home within 24 hours of having responded to his station for a call? For all we know, that victim may have died without the call having happened at all. Add in suicides, if you will, and you will include the following:
Jumping from Height
Officials would have to sort through the complexities of these methods and the victims’ histories, if the details are made available, and then transfer it to related training information. Ask any fire chief, line officer, training officer or firefighter doing training what the low hanging fruit of preventing firefighter fatalities is and you can be certain that preventing suicides is not one of them.
Just like trying to include a victim who died of natural causes in his bunk at the firehouse, using a NIOSH report that says “The following recommendations would not have prevented the [victim’s] death. Nonetheless, NIOSH investigators offer these recommendations to address general safety and health issues,” for training, details on suicide will be viewed as irrelevant when compared to the more popular (widely embraced/recognized/shared) fireground fatalities and apparatus accidents.
I leave you with a word of caution about relying on statistical data and victim information as a support for on-duty death inclusion. Information about suicides presented to chief officers shares that while the death should be openly discussed, the method or means of the death should not be described[iii]. Now, by using a ‘best practice’ to eliminate stigma, you’ve also just made the details irrelevant.
Forcing It on Others and Tarnishing Honor
Suicide, for anyone, is a hard subject to discuss. Personal views range from what a person reads in the media to what a family member or coworker experiences. Just as those views are many, so are the acts of suicide, or what behavior the victim believed in that led to the decision to act. Not every firefighter suicide is a product of post-traumatic stress disorder (PTSD). Some may involve criminal or socially inappropriate behavior. Others may involve a murder-suicide. The trouble with these and the victim who acts out of despair is that the value placed, right and wrong, on on-duty deaths is one of honor. Many have written on this subject, a ‘duty to die’, in an effort to change attitudes and lower the number of firefighter fatalities. The view of suicide, in and out of the fire service is one of cowardice. To officially add firefighter suicides to on-duty death information distorts the efforts made by others to change cultural attitudes and the value placed on existing on-duty deaths in their recognition by the fire service and the public.
I have had the privilege to speak with many in the fire service, from firefighters to chiefs and commissioners, on this subject and while all agree that we need to work together to bring the subject out in the open and work on preventative measures, those who have experienced a suicide have had different reactions. One firefighter spoke to me about how when a member of his shift had killed himself, the others were practically ostracized by the other shifts and department. Another firefighter told me how his department wanted nothing to do with the funeral of a firefighter who took his own life and pushed the firehouse to “get over it” as members tried to cope. A chief told me the unique time when a member took his own life and the department wanted to provide a nice funeral for the family. Unfortunately, due to some details about the death and firefighter the department wasn’t privy to, the family wanted to have nothing to do with a funeral or any other type of service. This left the members in limbo for how to grieve and speculate about what they didn’t know of their colleague.
It is a sticky mess, dealing with the family and adding suicide it becomes stickier. One item that was stressed by many of the participants and presenters of the NFFF workshop was that the wishes of the family should come first. This is hard for the fire service because many see on-duty death identification and a LODD funeral as a salute to the service the victim provided. We see this with the non-LODD funerals given to members who have died. However a department wishes to provide a memorial service for its deceased members is one thing, but to have emotion be the leverage for why a suicide should be placed on par with a collapse or heart attack victim is another. PTSD is not the only factor in the contribution of suicides and as already shared and can be documented, the data on firefighter suicides is incomplete. How can we add to the reports and list of names a victim whose death we may never know the full details of, among those who in most cases we know all the steps that lead up to their end? Many will question how does this honor the sacrifices of others? What do we say about valor and courage (and I openly admit that not every firefighter fatality is about those) when we place alongside it what others – and ourselves – may consider cowardly and selfish? It is a sticky mess indeed.
The Implication of Saying Something and Doing Nothing
If as proponents suggest, we add firefighter suicides to official on-duty deaths, then onus of preventing them, like the other fatalities, is on the fire department. We have all read of news stories about line of duty deaths where the municipality was fined by OSHA, the widow sued the department and the union called out the chief. In most of these stories, the underlying issue was a failure to act or prevent the tragedy. While the current efforts to prevent firefighter suicide should be widely adopted, by adding suicide as an on-duty death we have now put departments in a hard position of having to prevent them just like they would prevent members from not wearing their seat belts, not using all of their PPE or not establishing a collapse zone. This becomes a huge gray area between legal cause to act/intervene, information confidentiality, public image and funding for resources. Take this to an already overtaxed, underfunded department, or better, a volunteer department that can barely deliver health and fitness improvements to its members and having to deal with suicides as a preventable act equal to fireground and apparatus safety will frustrate the lot of them and cause a fear of liability.
It’s Not about Service or Emotion
It is important to understand, as I always do when I write about on-duty deaths, that the discussion doesn’t focus squarely on the victim, but on related information (data, status, and training) and must be done outside the context of the victim’s service to the department and without the passion or emotion. When others say that firefighter suicides should be listed as on-duty deaths they are saying that the victim needs to be remembered in some officious manner. They say this because of emotion and without knowledge (or maybe a blind eye) of the existing national criteria and definitions. When emotion is allowed to run contrary to the science (even if it is imperfect) of the data, all the data is in jeopardy of being misinterpreted. Likewise, citing PTSD as the main reason for including firefighter suicides is also bent on emotion and shows a misunderstanding of suicide in general.
Before we can ever get to a discussion on a national level about this subject, we should first encourage our shifts and departments to talk openly about how we would handle the suicide of one of our own and his or her family. Everything beyond that is data and we need to be careful to not let emotion influence the facts.
Finally, for the matter of transparency and for the eventual “you don’t know how it feels” rebuttal, I offer this:
Yes, my department has experienced the death by suicide of one of its members.
Yes, I even considered and planned my own suicide. I was stopped and thankfully received help.
That’s all you need to know. Anything else is just emotion.
p.s. Might as well add that this view does not reflect the view of my employers and those related to them or anyone else associated with me and fear some form of social ostracizing or being unfriended on Facebook. I'd hope that if this makes you mad, you would at least turn that energy into making your department have this discussion. - Bill
"In order to know a community, one must observe the style of its funerals and know what manner of men they bury with most ceremony."
[i] “While we don’t know the exact data, based on general population rates, we are three times more likely to experience a firefighter suicide over a line of duty death.” R. Gist, NFFF Suicide Workshop, Emittsburg, MD 26-27 October 2013
[ii] “Contrary to common belief, we do not really know the scope of firefighter/EMS suicide, because suicide data as related to occupation has previously not been systematically recorded or reported. Since many firefighters (upwards of 75%) are volunteers, the relationship between occupational stress and suicide becomes even cloudier.” Suicide: What you need to know – A Guide for Clinicians, NFFF 2013
[iii] “Suicide: what you need to know – A Guide for Fire Chiefs”, NFFF 2013