Chapter 12—Preventing I Injuries and Illness
Wildland firefighting and field work can be dangerous occupations. We must take steps to prevent injuries and illnesses, to treat injuries and illnesses that do occur, and to ensure a worker's successful return to work.
Prevention begins long before the field season; it includes physical preparation, good nutrition, and work hardening. A firefighter should begin the fire season well rested.
Fitness—Fit workers are less likely to be injured, and they're likely to recover more quickly after an injury. Debilitating back and repetitive trauma problems are less common in workers with adequate muscular fitness. Workers who engage in core training (see appendix G) improve performance and experience fewer back problems.
Training—Training involves more than physical fitness. Firefighters need to learn and practice proper lifting techniques to avoid back problems. Training in the efficient and effective use of tools also is essential. Workers should be cross trained to reduce the likelihood of repetitive trauma disorders. Simply changing jobs or tools now and then will reduce the repetitive strains and trauma associated with certain tasks.
Safety awareness and training are important, as are the examples set by crew leaders and managers. Workers respond to safety messages that are communicated by action and deed. Workers need to understand and appreciate the values and limitations of protective equipment and become proficient in its use and care.
Ergonomics—Ergonomics implies selecting the right tool for the job as well as the right person for the tool. Our studies show that certain tools, such as the combi tool, are more effective and less fatiguing than the Pulaski and that some workers are more capable with certain tools. Field work and firefighting in remote sites limit the use of power tools, increasing the importance of workers' fitness and skill with handtools. Because we can't adapt the job to the worker, we must adapt the worker to the job.
On the Job
Warmup—Workers, like athletes, need to warm up before strenuous effort. A gradual increase in muscle and body temperatures improves metabolic and neuromuscular efficiency. Warm muscles and stretched tissues are less susceptible to injury. Stretching also helps relieve soreness. Use stretching and a gradual transition to work to ease into the workday.
Work and Rest—Fatigue often is a cause of accidents; make sure that you get enough rest. Breaks, short or long, are a defense against fatigue. Sleep is another. To perform well at tough jobs like wildland firefighting, workers need to average 1 hour of rest for every 2 hours of work. This rest-to-work ratio means that a 14-hour work shift is about as long as crews can work and still get the sleep and rest they need. The shift should allow time for eating, showering, and getting ready for work. Sleeping conditions should be quiet, warm, and dry. Night crews need protection from noise, light, dust, and other conditions that interfere with restful sleep during the day.
Field studies by the University of Montana and the Missoula Technology and Development Center show that firefighters' immune systems fully recover after 14-hour shifts but not after 21-hour shifts. Crew bosses should follow hard days with easier ones to allow time for recovery.
Energy and Hydration—Workers are responsible for maintaining their energy and fluid intake. Supervisors can make sure adequate food and drink is available, but the workers themselves are responsible for taking the time to eat and drink. Failing to do so makes workers a hazard to themselves and their coworkers. Supervisors should schedule breaks every 90 minutes, especially late in the shift. Fluids should be replaced regularly, with firefighters drinking every 15 to 30 minutes during hot conditions.
No job is worth an injury, yet jobrelated injuries do occur. Slips, trips, and falls are common in field work. Firefighters experience ankle, knee, and back injuries. How can we limit these injuries and speed employees' return to work?
Treatment
For soft-tissue injuries that are not severe, appropriate treatments minimize the extent of the injury and ensure a quick and complete recovery. Most soft-tissue injuries are treated with RICESS (Rest, Ice, Compression, Elevation, Stabilization, and Stretching).
This simple treatment plan, if followed properly, has a dramatic effect on recovery. Use ice as often as possible in the first few days after the injury. Use compression to avoid swelling. Elevate the leg as necessary to control swelling. When pain and swelling are controlled, stabilizing the ankle allows a return to limited activity and rehabilitation.
Rehabilitation
Firefighters with serious injuries should receive rehabilitation under the guidance of an athletic trainer or physical therapist. Rehabilitation involves a progressive program designed to restore muscle strength and endurance, range of motion, and full functional use. The ability to perform under field conditions should test the employee's readiness to return to work. Physician approval will be required after recovery from serious injuries.
Well-designed rehabilitation programs return workers to full activity in the shortest possible time. With physician approval, workers may return to work with the aid of protective taping or bracing. Leg, back, wrist, and other braces are becoming common in the workplace, but there is little proof that they prevent new or recurring injuries. Braces are no substitute for training or rehabilitation. Workers should not return to work until they can do so safely, without becoming a hazard to themselves or to their coworkers.
Treating a Sprained Ankle Using RICESS
Rest-Rest is used to relieve swelling and to allow treatment (ice and elevation). Otherwise, some mobility is desirable, so long as discomfort and swelling are controlled.
Ice-Ice (which could be a cold pack, a frigid mountain stream, or snow in a plastic bag) is the treatment of choice for acute soft tissue injury. Cold slows metabolism, reduces bleeding and swelling, reduces pain, and limits the extent of the injury. Apply ice for 20 to 30 minutes several times a day for best results. Continue for several days or until the swelling and pain are gone.
Compression -An elastic wrap soaked in cold water provides compression and cooling shortly after the injury. A dry wrap continues compression between cold treatments.
Elevation-Elevating the limb limits the swelling after an injury. A badly swollen sprained ankle should be elevated above the heart as much as possible during the 24 hours following the injury.
Stabilization-Workers can use tape or ankle supports to stabilize the ankle.
Stretching-While stretching may be viewed as part of rehabilitation, gentle stretching may begin shortly after the injury. Flexion and extension exercises can be done while applying ice, compression, and elevation.
Return to Work
Before firefighters are allowed to resume firefighting, they should be able to pass the job-related test they passed before being hired. For example, a firefighter should be able to pass the test used to establish job-related work capacity. This will demonstrate recovery from the injury as well as the fitness for duty. If no test is available for the job classification, performance of key elements of the job will provide some assurance of job readiness. Because of the risk of subsequent injury, smokejumpers require a more demanding test. Dr. Michael Schutte, an orthopedic surgeon and specialist in sports medicine, has used a jumping test to evaluate a jumper's readiness for return to work.
Workers want to rejoin their crew and return to work as quickly as possible. Medical clearance and an appropriate field evaluation will ensure their readiness for work without undue risk of subsequent injury.
When living with a large number of people in a fire camp or even when spiked out with your crew, take care to avoid the spread of bacteria and viruses. Wash your hands before meals or handling food. Don't share water bottles. If you need to share water, pour the fluid from one bottle to another.
An ongoing study has found high concentrations of bacteria and other microorganisms in water containers that were not regularly washed. Firefighters who use sipping hydration systems need to wash the reservoirs, hose, and mouthpiece occasionally. Flavored beverages containing sugars should not be used in sipping hydration systems.
Immune Function
The human immune system is a complex arrangement of organs, tissues, and cells that protect the body from infectious microbes (including viruses, bacteria, fungi, and parasites). Up to 50 percent of the visits to fire camp medical tents are for upper respiratory problems, including coughs, colds, and sore throats. Factors in the firefighting environment known to compromise immune function include: fatigue, exhaustion, stress, inadequate energy and nutrition, dehydration, smoke, sleep deprivation, and environmental extremes. Wildland firefighting presents a challenge to immune function and health.
The secretory immune system of the mucosal tissues of the upper respiratory tract is considered the body's first line of defense against infiltration by pathogens. Salivary immunoglobulin A (sIgA), the major component of that system, inhibits pathogens from attaching themselves and reproducing, preventing them from entering the body. Numerous studies have shown that sIgA decreases significantly after a bout of prolonged, intense effort, such as a marathon run. Up to 25 percent of the finishers in the marathon will experience an upper respiratory tract infection within 2 weeks afterward (the percentage is more than 50 percent after longer events).
This decline in sIgA after arduous effort allows viruses and bacteria to gain a foothold, increasing the likelihood of infection.
Carbohydrate supplementation during long shifts of arduous firefighting enhances maintenance of immune function, improves recovery, and allows firefighters to accomplish more (fig 12.1). The mechanism for the improved immune function may be related to a decrease in cortisol, a stress hormone that causes immune function to decline. Carbohydrate minimizes the production of cortisol.
Figure 12.1—Immune function decline and recovery after hard work, with and
without carbohydratesupplementation (Harger and others 2004).
Studies also show that sIgA decreases even more after very long work shifts, which may require a day or two of relative rest for recovery. The immune function of wildland firefighters becomes depressed after hard work (more than 3,000 kilocalories), especially after a number of days of hard work (figure 12.2). The fatigue index, using a simple standardized step test, appears as sensitive as sIgA in identifying patterns of fatigue and immune depression. Although these data suggest that physically fit wildland firefighters can sustain arduous duty cycles, days of lighter activity should be interspersed to maintain immune function and avoid accumulative fatigue (see appendix I for more information on the fatigue index).
In figure 12.2:
- Bars represent relative
work during each shift.
Bars at the height of the
horizontal line represent
about 4,000 kilocalories of
energy expenditure.
- The light line represents
the percent change in the
fatigue index.
- The dark line represents change in sIgA (measured in milligrams per milliliter).
Figure 12.2—Changes in salivary IgA and fatigue index after days of variable energy expenditure.
Larger fatigue index values represent fatigue. Values that return to 0 percent reflect recovery. Negative sIgA values indicate immune function suppression. (Gaskill and Ruby 2004).
Recovery—Time for rest and recovery should be included during training and during work. Failure to provide time for recovery could lead to suppressed immune function and an increased risk of respiratory infection. Recovery must consider all the factors that affect immune function, including exhaustion, inadequate rest, poor nutrition (not enough energy, fruits, and vegetables), dehydration, stress, and smoke exposure. Smoke depresses immune function and deadens the actions of the cilia in the lung. Cilia sweep particulate up and out when it is entering the lung. When the cilia stop their work, particulate can slide deeper into the respiratory tract. Prolonged smoke exposure can lead to bronchitis or even pneumonia. Schedule rest days in a smoke-free environment to ensure recovery.
See appendix J for warning signs and medical issues related to training, testing, and performance of physically demanding work.
Stress—Stress is a response to events that are perceived to be physically or psychologically threatening. The body's endocrine system responds by producing hormones for the fight-or-flight response. However, prolonged exposure to these hormones can lead to immune suppression and increased susceptibility to infection and illness.
Fatigue—Prolonged exertion and exhaustion lead to suppression of the immune system, vulnerability to upper respiratory infections, and slow healing of wounds, as well as poor performance, muscle soreness, irritability, sleep disturbances, and psychological problems, such as depression.
Nutrition—Just as certain nutrients (Vitamins C, E, and Beta-carotene) help maintain a healthy immune system, poor nutrition can weaken it. See the section on nutrition for more information on this subject.
Smoke—Chronic exposure to the smoke from cigarettes reduces immune function, influences the response to other agents (such as carcinogens) and increases the risk of heart disease, lung cancer, chronic respiratory problems, and other ailments. Prolonged exposure to the smoke from wildfires has the potential to cause some of these effects. However, firefighting is seasonal, exposure is episodic, exposures seldom exceed allowable limits, and the health implications of these exposures have not been determined. While smoke is a threat to the immune system, stress, fatigue, and poor nutrition also lead to poor immune function and increased risk of upper respiratory and other problems.
Firefighting and the Immune System
While the smoke from forest fires is not considered immediately dangerous to life and health, it does cause unpleasant symptoms (production of phlegm, coughing, wheezing, sore throat, burning eyes) and sometimes leads to respiratory illness. A number of factors in the firefighting environment reduce immune function and increase the body's susceptibility to respiratory and other illnesses.
To maintain a healthy immune system and minimize the risk of respiratory illness, avoid prolonged exposure to smoke, manage stress through communication and training; improve fitness, use rest and labor-saving tools to minimize fatigue, and eat a variety of vegetables, fruits, and other immune friendly foods.
