Abstract
Introduction
Firefighting is consistently cited as a hazardous occupation given the physical characteristics of the job and the high rates of injuries [1]. Every year, thousands of firefighters are injured while attending to on-duty responsibilities such as fire suppression, medical emergencies and physical training [2]. In addition to the physical, psychological, emotional and financial costs that injuries impose on affected firefighters and their families, the associated disability, medical (treatment and rehabilitation), and overtime costs borne by fire departments [3] place tremendous financial strain on a municipalities that may already be operating with limited resources. In 2004, the National Institute for Standards and Technology estimated that the total annual cost of firefighter injuries in the United States alone could exceed $7 billion [4]. Because the cost of injuries lend some insight into their severity, [5] a detailed description of the compensation claims, including the associated job duty, motion pattern, and injury type and body location could assist with the design of targeted prevention strategies to attenuate the incidence, prevalence and severity of firefighter injuries [6].
Comprehensive wellness, fitness, or job-training programs may provide participating fire departments with a positive return on investment; [5, 8] however, at present, there is limited information available linking the cost of firefighter injuries to the types of injuries being sustained. Bylund and Björnstig [9] examined the injury reports of 111 Swedish firefighters between 1989 and 1991, and found that 67% of the direct costs, which included payment for constructive damage (i.e. pain, suffering, and impairment), sick leave and medical treatment, could be attributed to exercise and training-related injuries. In the second study, Walton et al. [3] reviewed 1343 compensation claims filed by firefighters from northeastern Illinois between 1992 and 1999, and showed that injuries categorized as a sprain or strain, or overexertion were 80% more costly than any other injury type or mechanism, respectively (per-claim cost for overexertion injuries was $9,715). Aside from these data that were collected more than twenty years ago, there is little information currently available to scientists, ergonomists, and workplace health and safety personnel regarding the cost of firefighter injuries. For this reason, it can be challenging for fire departments to identify or design suitable interventions to attenuate the personal and economic impact of injuries sustained while on the job.
The purpose of this study was to describe the number and direct costs of injuries sustained by firefighters from a large Canadian metropolitan department. Musculoskeletal injuries were further categorized by job duty, general motion pattern, injury type and body part affected. This information could provide an opportunity to develop customized injury prevention strategies for individual fire departments, while offering general insights that are relevant to all emergency responders.
Methods
Population
This study examined the injuries sustained in 2012 by the Calgary Fire Department (CFD), a large metropolitan department in Western Canada. In 2012, the CFD consisted of 1289 uniformed staff (i.e. firefighters, lieutenants, captains, and district, battalion, and deputy chiefs) and served 1.1 million residents from 38 stations. Firefighters and apparatus responded 102,632 times to 52,918 incidents, the most common of which were medical emergencies (49%), followed by false alarms (16%), hazardous conditions (15%), investigations (8%), and public service assistance (7%). Only 4% of all dispatches involved fire suppression activities.
Data source
Injury data were taken from reports filed by CFD personnel in 2012. Included in these reports were details regarding the type of injury (e.g. sprain and strain), body part affected (e.g. knee), job duty (e.g. medical emergency), and a written description of the circumstances surrounding the event. For the purpose of this study, a reportable injury was defined in accordance with the Occupational Health and Safety regulations for Alberta, namely medical treatment, restricted work duties or lost time, which was defined as missing one or more shifts because of an occurrence. Injuries sustained to any specific body part were also included in the analyses, as were those that manifested over a period of time, but could not be attributed to any single event (i.e. cumulative load or “chronic” injury).
Cost data were taken from claims filed with the Workers’ Compensation Board (WCB) of Alberta between January 1, 2012 and December 31, 2012. Each record distinguished between medical aid and compensation, which included lost wages and/or the cost of retiree hiring someone to assist with daily activities. Cost estimates reflect the claims’ status as of February 6, 2013.
Classification of injuries
All injuries reported in this study were described by type (i.e. sprain/strain, cut, bruise, fracture, burn, and other), body part affected, and job duty [6]. Using documented accounts of the actual events (e.g. “strained low back lifting a 250 kg patient at a medical call”), sprain and strain injuries, defined herein as musculoskeletal disorders (MSDs), were also categorized by the general motion pattern employed at the time of injury (e.g. lifting, squatting, lunging, pushing, pulling) [10]. More specifically, inferences were made regarding the kinetics (e.g. low back demand moment) and kinematics (e.g. spine flexion) of the associated activity based on details provided in the injury reports. In this way, tasks performed as part of any job duty that were of similar biomechanical demands could be categorized using the same general motion pattern. For example, bending, lifting and squatting were characterized as being alike because each activity comprises a forward trunk lean and an external flexion moment about the low back. Similarly, climbing stairs and stepping off the fire truck were assigned to the same general motion category given that both are tasks involving a single-leg lunge-type pattern. Running could also be considered a lunge pattern; however, it was deemed different because it is typically associated with higher movement speeds (and ground reaction forces) than would be expected while stepping. The general motion patterns included in this study were: 1) LFT – bending, lifting and squatting (e.g. lifting a patient); 2) JUMP – jumping and landing (e.g. jumping off truck; 3) STP – lunging and stepping (e.g. stepping off truck); 4) RUN – running (e.g. jogging on the track); 5) PSH – pushing and pulling (e.g. forcing a door); and 6) SIT – sitting (e.g. riding in pump). When insufficient detail was provided in the event description (e.g. “injured back while working out”), or when an injury could not be categorized using one of the abovementioned patterns (e.g. “hurt left wrist turning screwdriver”), injuries were grouped into “training”, “fireground”, or “other” job categories. Injuries associated with a slip, trip or fall (SLP) were also uniquely identified and not characterized by a general motionpattern.
Data summary
Injury and cost data were summarized in absolute terms (frequencies and magnitudes) and as percentages of the total number of injuries and WCB costs, respectively. The incidence and cost of MSDs were further categorized by body part, job duty, and general motion pattern.
Results
Number of all injuries
A total of 244 injuries were reported by CFD in 2012, of which 159 (65%) were categorized as MSDs (Fig. 1). The most commonly reported MSDs were to the back (32%), knees (23%) and shoulders (15%). Of the 65 MSDs resulting in lost time, 35% affected the back. Of the 85 injuries not categorized as an MSD, cuts and lacerations were found to comprise the highest percentage (34%), followed by bruises (22%) and fractures (12%). Twenty-two percent of these injuries were associated with lost time (Fig. 1).
Cost of all injuries
The combined medical and compensation cost of injuries in 2012 was $555,955, of which 77% was for MSDs (Fig. 1). Knee injuries were most costly ($157,383), followed by those affecting the back ($100,459) and shoulders ($76,838). Knee-related MSDs were also found to be the most costly when expressed on a per-injury basis (Fig. 1). The most costly non-MSDs were bruises and contusions ($26,546), and fractures ($24,765).
Musculoskeletal injuries by job duty
Categorized by job duty, 31% of all MSDs were sustained while attending to responsibilities at the fire station (Table 1). Physical training in the gym or at the training center was associated with 28% of all reported sprains and strains, followed by 18% for both fire and non-fire emergencies. The job duty associated with the highest compensation costs was physical training (34% of all MSD-related costs). Station-related activities, non-fire emergencies, and fireground operations were attributed to 29%, 17%, and 16% of the MSD-related costs, respectively (Table 1).
Musculoskeletal injuries by general motion pattern
Categorized by the general motion pattern used, 23% of all MSDs were described as LFT-related (Table 2). Injuries given this designation wereassociated with 20% of the MSD costs. Activities described as STP, which included getting into and out of the apparatus, were associated with 15% and 17% of the injuries and costs, respectively. RUN-related injuries contributed to 16% of the total costs, although only 7 were reported (4% of MSDs).
MSDs categorized as SLP accounted for 18% of all injuries (Table 2), while exercise and training activities not categorized using one of the abovementioned descriptions were attributed to 15% of all claims. Injuries given these two designations were responsible for 15% and 9% of the MSD-related costs. Fireground injuries not categorized using one of the general motion patterns accounted for just 4% of the MSDs reported, and only 1% of the total costs.
Musculoskeletal injuries by job duty and general motion pattern
As shown in Table 3, 18 of the 29 MSDs, and 91% of the costs associated with fireground operations could be attributed to STP and SLP activities. LFT-related injuries were the most costly and most commonly reported MSD at the fire station and during non-fire emergencies (Table 3). Of the 44 injuries associated with physical training, 40% were characterized as LFT, JMP, STP, RUN, or PSH. Collectively, these general patterns contributed to 73.0% of the total physical training-related costs, the highest of which were associated with RUN. An additional $38,467 was spent on training-related injuries that could not be categorized using one of the general motion patterns.
Discussion
Contrary to previous reports, [2, 11] fire station-related duties and exercise and physical training were associated with the most common and costly injuries reported by CFD, respectively. While these findings are challenging to interpret without knowing how much time was spent performing each type of activity (e.g. CFD personnel may spend more time engaging in exercise and physical training than on the fireground), they do highlight one of the primary reasons why CFDs injuries were categorized by the general motion pattern, body part affected, and injury type and location, in addition to job duty. To direct the development of a suitable injury prevention strategy for any organization requires a better understanding of the prevailing injury mechanisms that contribute to both the incidence and cost of MSDs.
MSDs were the most common (65% of all claims) and costly (77% of total) type of injury reported by CFD personnel; however, the average cost per MSD was substantially lower than that reported by Walton et al. [3] for a group of American firefighters, both when compared to the authors’ total cost estimates ($2,708 versus $8,301), which included fees for medical, compensation, legal, vocational therapy, and “other”, and when the medical expenses were considered alone ($3,023). Though not presented with the current findings, the average cost of medical aid for injuries reported by CFD personnel was just $852. Because of differences in the American and Canadian health care systems, compensation boards, and currencies (including inflation), it is somewhat challenging to make direct comparisons with the results reported by Walton and colleagues [3] but, the data do suggest that the injuries reported by CFD personnel were probably less costly than those reported by the American firefighters sixteen years ago, perhaps because CFD provides considerable support and infrastructure for their members to maintain their health, wellness, and physical fitness.
Although it is currently impossible to know whether CFD members’ muscular strength, endurance, cardiorespiratory efficiency, or flexibility influenced the cost of injuries reported, there is evidence to suggest that firefighters with superior physical fitness levels experience less costly injuries than do their peers who are less physical fit [7]. A protective effect was first shown by Cady et al. [7] when it was concluded that the number and cost (severity) of lower back injuries was associated with firefighters’ level of conditioning. In 1990, Hilyer et al. [5] found that a flexibility intervention had little effect on the incidence of firefighter injuries, but it significantly reduced the costs associated with lost time. More recently, Jahnke et al. [12] reported that firefighters who exercised on-duty were half as likely to report non-exercise injuries at work. However, consistent with the data reported here and elsewhere, [6, 11] Jahnke and colleagues [12] also found that a large percentage (33.3%) of the injuries reported by fire service personnel occurred during on-duty exercise- and training-related activities. Being physically fit might help to reduce the cost and/or severity of MSDs, but these data suggest that additional research is needed to design exercise programs and training activities that are safer for firefighters, particularly given that across all CFD job duties physical training-related injuries were associated with the highest costs.
Limiting the amount of time that firefightersspend exercising and training is likely an unrealistic and perhaps irresponsible solution to prevent injuries and lower the associated costs. The health-related benefits of exercise have been well established [13, 14] and the physical demands of the occupation dictate that high physical fitness levels are needed to perform many essential job skills. [15, 16] Further, such a proposition assumes that there are no cost savings to being physically fit, despite evidence to the contrary [7]. To address the cost of firefighting injuries it may be more appropriate to examine the nature (and mechanisms) of the injuries being reported so that exercise and training can be used to elicit behavioral changes that could impact firefighters’ safety and effectiveness. Frost et al. [17] recently showed that a 12-week exercise intervention designed to improve firefighter fitness could change how participants’ performed a battery of occupational tasks when an emphasis was placed on “key” aspects of their body mechanics (e.g. maintaining spine and frontal plane knee motion control). Although no clear differences were observed in low back loading, [18] firefighters who did not receive movement-based feedback or instruction were more likely to perform their occupational tasks in ways that have been associated with knee and low-back problems.
In the current study, exercise- and training-related injuries contributed to 34% of the total costs. However, aside from RUN, the general motion patterns attributed to each incident (e.g. LFT, STP and PSH) were similar to the MSDs reported across all job duties. In fact, more money was spent on LFT injuries that occurred while attending to station-related responsibilities and non-fire emergencies than during exercise or training. Likewise, the highest costs associated with STP incidents, of which 67% involved exiting the apparatus, were attributed to station duties and fire-related calls. When categorized by motion pattern, 91% of all fire-related costs were associated with either STP or SLP; a finding that probably reflects the type and distribution of CFD calls. In 2012, 20% of all first responses involved an indication of fire, yet only 4% required suppression activities. This implies that the majority of calls likely involved getting on and off the apparatus without having to engage in high-risk unpredictable work. Based on this information, developing a training strategy to prevent STP and SLP injuries that occur while exiting the apparatus (e.g. exit backwards, keep the knee hip and foot aligned) may be one of the most effective ways for CFD to lower the cost of fire-related MSDs. With sufficient practice, firefighters may also be more likely employ this safer STP pattern while performing other relevant tasks (i.e. transfer of training to unrehearsed activities), thus reducing their risk of STP-related MSDs across several job duties.
Given advances in ergonomics and exercise science, it has become increasingly common for firefighters to be taught and encouraged to engage in training-related activities that can influence how they perform a range of occupational duties [17, 19]. Ultimately, this approach may have a bigger impact on the prevention of work-related MSDs than efforts to increase fitness alone, though the extent to which it can lower injury rates and reduce costs will probably depend in part on the type of information collected about the injuries reported. Knowing that low-back injuries are commonly reported while lifting, for example, could help to identify a list of potential injury mechanisms (e.g. lumbar spine flexion under load) and guide the development of a prevention strategy to target lifting-related lower back injuries (irrespective of job duty). For example, Suni et al. [20] documented a reduction in the incidence of low back pain amongst military personnel following a 6-month exercise/education intervention designed to improve participants control of spine motion. In 2012, CFD’s most frequent and costly injuries were knee and back MSDs; 57% of the knee-related costs were attributed to stepping and running, while the majority of back injuries (62%) could be attributed to lifting. Although it is unlikely that all of these injuries and the associated $152,766 could have been prevented, having this information will help to design an exercise and/or training program that promotes behavioral changes that are relevant to the occupational demands of CFD personnel (e.g. modify personal physical and psychological characteristics to enhance movement effectiveness and safety at work).
Funding
No funding was received to complete this work
Conflict of interest
Ian Crosby is a member of the Calgary Fire Department. The other authors have no conflicts to declare.
Footnotes
Acknowledgments
The authors would like to express their gratitude to all members of the Calgary Fire Department for their cooperation on this project and continued efforts within the community.