Firefighter Concussions

In the sports world there is an increasing awareness of collision induced concussions between football players, soccer players, kids on the playground and others engaged in contact sports other than dancing. There are many other ways to get a concussion. Some common ways include fights, falls, car crashes, and bike accidents. Concussions can also happen while participating in any sport or activity such as football, boxing, hockey, soccer, skiing, or snowboarding.

Some states have mandated qualified trainers to evaluate possible concussion symptoms in a “play, don’t play scenario” to be on the sidelines evaluating players suffering from head trauma. In fact, Washington state enacted the Zackery Lystedt Law after a 13-year-old middle school football player collapsed from a traumatic brain injury and was allowed back into a game just 15 minutes after suffering a concussion. Zackery spent the following nine months in a coma, and even today still sits in a wheelchair, having regained his sight and ability to speak but still struggling to regain strength in his left leg and foot. 

Firefighters bump or bang their heads on an almost daily basis during the job. Debris fall onto the helmet, coming up under an open compartment door, getting into or out of the apparatus banging your head on the door frame and other seemingly “innocent” occurrences which we tend to shake off. It appears we only become concerned when we “see stars”, get a headache after we hit our heads or are knocked unconscious. A review of the fire service trade literature and media sources reveals an astonishing number of firefighters suffering a head injury while on the job. A horrible example is the Georgia Firefighter who died after being struck in the head by a hose coupling, suffering a traumatic brain injury. He was reportedly gearing up at the time that other crews were laying out.

Head injuries are more frequent than we would imagine, although not specifically recorded in the annual NFPA statics, we do suffer from the after effects. According to the United States Fire Administration report Fire Related Firefighter Injuries Reported to NFIRS (2012 – 2014) released in the Topical Fire Report Series Volume 17, Issue 6/August 2016 indicates, 14.2% of the 66, 200 injured from all sources were reported as head injuries. That is 9,400 occurrences and it is a significant issue for the fire service.

A concussion is a type of traumatic brain injury that is caused by a blow to the head or body, a fall, or another injury that jars or shakes the brain inside the skull. Although there may or may not be cuts or bruises on the head or face, there may be no actual visible signs of a brain injury.

Your brain is a soft organ that is surrounded by spinal fluid and protected by your hard skull. Normally, the fluid around your brain acts like a cushion that keeps your brain from banging into your skull. But if your head or your body is hit hard, your brain can crash into your skull and be injured.

You don't have to lose consciousness to have a concussion. Some people will have obvious symptoms of a concussion, such as passing out or forgetting what happened right before the injury. But other people won't. With rest, most people fully recover from a concussion. Some people recover within a few hours. Other people take a few weeks or months to recover.

In rare cases, concussions cause more serious problems. Repeated concussions or a severe concussion may lead to long lasting problems with movement, learning, or speaking. Because of the small chance of serious problems, it is important to contact a doctor if you or someone you know has symptoms of a concussion.

Many times, firefighters will make the statement after they get hit in the head, that they “saw stars” or “got their bell rung”. For some, it is a stiff neck or shoulders or an intractable headache that Tylenol won’t alleviate. Some indicate they are nauseous or can’t keep their balance.  Those are the subtle signs of a concussion. Head injuries that cause a concussion often occur with injury to the neck and spine.

The concussion medical exam will be subjective and based upon the history of the event and the symptoms you suffered or are continuing to suffer from.

Other health issues are also directly related to head injuries or concussions, especially repetitive head injuries found in contact sports or certain occupations like firefighting to include depression. It is just one mental health issue associated with concussion injuries and its associated syndromes.

Depression and other mental health issues are a hot topic in the fire service and we need to be aware there are concussion induced mental health issues. We don’t need to “man up” or “suck it up” in today’s fire service as there are too many examples of firefighters whose health is affected by these concussive events.

 Symptoms of a concussion can range from mild to severe. They can include:

The following are emergency symptoms of a concussion. Seek immediate medical care if there are:

While recovering from a concussion, you may:

 A qualified medical practitioner will perform a physical exam and check your nervous system. There may be changes in your pupil size, thinking ability, coordination, and reflexes.

Some tests that may be performed to determine a concussion include:

 Recovery

Healing or recovering from a concussion takes time. It may take days, weeks, or even months for a concussion to improve. Individuals and caregivers must learn how to treat the symptoms, how to monitor for problems, and when to allow the firefighter to return to normal activities.

You may be irritable, have trouble concentrating, be unable to remember things, have headaches, dizziness, and blurry vision however these problems will probably go away slowly. You may want to get help from family or friends before making important decisions.

Long-term problems are rare but may include: Brain swelling, which can be life threatening; if you have a second concussion while still recovering from the first one; long-term changes in the brain if you have future brain injuries and in a small group of patients, symptoms of the concussion stay for a long period of time. If symptoms do not go away or are not improving after 2 or 3 weeks, talk to your doctor for a re-evaluation.

A return to work clearance by a qualified neurologist or other specialist should be on the list of requirements for departments allowing their firefighters to return to work.

Helmet Technology

Firefighter helmet and head protection comes in all shapes and sizes. All fire helmets are certified and tested by a variety of organizations ensure firefighter safety including the NFPA and most meet the general purpose and utility of the firefighting activities. They shed water, protect the user from light or glancing blows but are they effective with high speed impact that tends to knock or dislodge the helmet from the wearers head? My answer would be no, since many firefighters do not wear the chin strap which is only designed to keep the helmet on the head of the wearer, there is inadequate internal protection against heavy or high speed impact and the configuration of many of the helmet styles are prone to be dislodged when struck.  

As football apparently creates the most significant concussions, a company in Seattle (WA) called VICIS using the most up to date research and technology, has taken it upon themselves to develop a helmet that will reduce the number of concussions from the football experience. The helmet is designed to deflect direct brain trauma from impact energy through an innovative method of an inner and outer helmet separated by small pylons designed to absorb energy and dissipate the rotational forces of a hit to the head.

Fire fighter helmets can be designed to do the same thing as the technology is available and possibly the traditional firefighter helmet could be relegated to ceremonial status (yes blasphemy) and not active firefighting. The US fire service are extremely traditional in their helmet choices. There are many innovative helmets from Europe and some in the United States that serves an extremely useful purpose in design protecting the brain from trauma.

We will see change in the future for head protection based on the prevalence of head injury and concussions found in firefighters when we reach a critical mass of significant head injury. I do not know what that number would be, but 9,400 head injuries to firefighters over two years is concerning.

Fire departments need to continue to focus on this health and safety issue and look to the protective clothing worn by the firefighters including their helmets and the technology used to protect firefighter brains.

References and Endnotes

1) Zachary Lystead Law https://www.doh.wa.gov/CommunityandEnvironment/Schools/Environmenta...

2) The Secret List www.FireFighterCloseCalls.com

3) Concussions - Webmd.com

4) https://vicis.co/

5) Ropper AH, Gorson KC. Clinical practice: concussion. N Engl J Med. 2007;356:166-172.

7) Hunt T, Asplund C. Concussion assessment and management. Clin Sports Med. 2009;5-17.

8) Biros MH, Heegard WG. Head injury. In: Marx JA, Hockberger RS, Walls RM, et al, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia, Pa: Mosby Elsevier; 2009:chap 38.