Trending Topics

Firehouse stress and takotsubo syndrome: Making the connection

Takotsubo syndrome might be a clinical trap, but the firehouse shouldn’t be

Fireman sitting on fire truck tired and sad

Takotsubo syndrome, also known as broken heart syndrome or stress-induced cardiomyopathy, can occur when a person experiences severe emotional or physical stress.

kali9/Getty Images/iStockphoto

By Dr. Lindsay Judah, CFO, CTO

“The world is complex and there are no quick fixes. But if I can learn to uncross my arms and extend my hands, I can be someone who eases suffering rather than ignores it.” — Dan Heath, “Upstream”

Have you ever tried to go to bed on a Sunday night, or before your next shift, and lay awake concerned with what the day will bring? No matter your position within an organization, you may experience bullying, intimidation, isolation and/or retaliation, or you may fear unknowns related to crew capabilities, funding, equipment reliability, staffing levels, policy changes and/or political climates.

Has your heart rate elevated just from reading this list?

Let’s consider how some common fire service experiences might impact our cardiac health and general well-being. Furthermore, how can we do better within the walls of the firehouse and administrative offices to protect our members from such stress?

Before we dive into these issues, let’s first explore a diagnosis that individuals may experience during periods of high stress, and consider the potential impacts of such stress on their physical wellbeing.

Takotsubo syndrome and stress

Takotsubo syndrome, also known as broken heart syndrome or stress-induced cardiomyopathy, can occur when a person experiences severe emotional or physical stress. This was first described in 1990 as a weakening of the left ventricle, the heart’s main pumping chamber. The name takotsubo comes from the shape of an octopus pot, a piece of pottery used by Japanese fishermen to trap octopus. When a patient is experiencing takotsubo syndrome, the left ventricle of the heart takes on the shape of the octopus pot.

While serving in the EMS/Training Division at the Tallahassee (Florida) Fire Department (TFD), I was afforded the opportunity to attend Acute Coronary Syndrome and Atrial Fibrillation (ACS/AF) review meetings. The ACS/AF committee attendees included cardiologists, an accreditation manager, nurses and partner agencies to include regional EMS and fire. The ACS/AF committee experience provided information to bring back to the prehospital providers at TFD. This was often completed by conducting EMS scenario-based training with personnel and utilizing previous case studies to share physician input and feedback.

STEMIs were commonly discussed during the case reviews. EMS providers throughout the region would declare a STEMI alert (based on patient presentation, as well as their training and protocols) and bring the patient to the receiving facility for definitive care. However, during our case review discussions, we found that some patients were later diagnosed with takotsubo syndrome. These patients presented with signs and symptoms of a heart attack and were taken to the cardiac cath lab where no coronary artery obstruction was found.

The March 2022 AHA Journal article “Takotsubo Syndrome: Pathophysiology, Emerging Concepts, and Clinical Implications” confirms the difficult-to-diagnose nature of the syndrome while highlighting alarming new information:

“Despite being described 30 years ago, its pathogenesis and pathophysiology remain poorly understood and the lack of treatments often presents a clinical dilemma for physicians. Previously believed to be a benign self-limiting condition, takotsubo syndrome is now known to be associated with substantial short- and long-term morbidity and mortality.”


A takotsubo diagnosis is commonly associated with a triggering stressful event, such as an unexpected death, domestic abuse, conflict, a major life event or even experiencing a disaster such as an earthquake or hurricane. Notably, one-third of patients do not recognize a discernable stressor. However, the patient may be reluctant to share personal stressful incidents, or clinicians may not explore underlying stress-specific challenges. According to a July 2022 article in the Journal of Personalized Medicine, the most common symptoms associated with Takotsubo included chest pain, dyspnea and sometimes palpitations or syncope. Further, as shown in the figure, the left ventricle is narrower near the top, and during systole (cardiac contraction), the midsection and tip (apex) of the left ventricle balloons out, replicating the shape of the traditional octopus pot.

Stress at the station

You may be wondering what this has to do with personnel wellbeing and overall organizational health. Let’s orient to that now.

We’ve established that there is a known cardiac condition (takotsubo) that has been studied for over 30 years – one that’s still not well understood among practitioners. While previously it was believed that this condition was self-limiting and not all that dangerous, studies now show that takotsubo syndrome is associated with substantial short- and long-term morbidity and mortality (illness and death). As such, taking measures to reduce stress is an important step in personal wellbeing and in prevention of takotsubo syndrome.

Furthermore, we know that fire and emergency services personnel are subject to stressful work environments that can be unknown and unfamiliar. The U.S. Bureau of Labor Statistics lists the occupation of firefighter as having one of the highest rates of injuries and illnesses, reporting about firefighters: “They often encounter dangerous situations, including collapsing floors and walls and overexposure to flames and smoke. Workers must wear protective gear to help lower these risks.”

While I agree the profession is inherently dangerous and often requires personnel to be sworn in when accepting a position, significant stress can be experienced by fire and emergency services personnel beyond the work of responding to routine or even unique incidents.

The questions become: Are personnel in our industry experiencing severe emotional or physical stress? Are these reasons why some are leaving the industry? Can we connect more with personnel and be of service to them as competent and devoted leaders?

The answer to all three questions is YES. The What Firefighters Want in 2023 survey revealed alarming statistics related to these very questions:

  • 76% rank their work-related stress as a 6 or higher;
  • 42% have considered leaving the fire service due to their stress;
  • 43% of respondents cited poor agency leadership as their #1 stressor; and
  • 53% said their supervisor’s stress level impacts the general wellbeing of other members.

These workplace challenges have been documented for over 30 years, much like takotsubo syndrome. However, the incidence of workplace stress may be much greater. Our fire and emergency services practitioners still have significant opportunity for improved awareness, alliance and action.

If we consider the dichotomy between acute and chronic stress, we can see that work-related chronic stressors may exist within the walls of the firehouse and administrative offices. Are we being our brothers’ and sisters’ keepers? Or are we torturing people wearing the same uniform? Are we observing bad behavior and turning a blind eye? As defined by Cambridge Dictionary, the idiom “turn a blind eye” means to ignore something that you know is wrong. Interestingly, the first and only example provided by Cambridge is, “Management often turn a blind eye to bullying in the workplace.”

Are we permitting a toxic climate and/or culture? Are we contributing to workplace dysfunction? If you are unsure of your role or how this might play out within your own organization, I encourage you to read “The Five Dysfunctions of a Team” by Patrick Lencioni and to familiarize yourself with the IAFC VCOS Yellow Ribbon Report Update, titled “Best Practices in Behavioral Wellness for Emergency Responders.”

These resources offer several key takeaways for first responders, including this one from the Yellow Ribbon Report: “First responders are some of the most tightly knit coworkers on the planet. We refer to our colleagues as brothers and sisters and family. We refer to our stations and buildings as houses. When all is well, there is nothing better. The negativity generated by a toxic work environment, on the other hand, has the ability to destroy the very fabric of those valued relationships or prevent them from developing. The resulting poor performance puts everyone at risk, including the community. And imagine what observing or hearing about a toxic work environment does to a department’s ability to recruit and retain productive personnel.”

For the love of the job

I recently completed a Sheriff Office Citizens Academy with the Pinellas County (Florida) Sheriff’s Office. One instructor shared this perspective about his job: “This is the greatest show on earth,” and his son is also joining the agency. I was taken aback by the atmosphere, sense of camaraderie, and genuine love they exhibited for their chosen career, also in public safety.

I had a conversation with a mentor of mine a couple months ago. He is now retired, but he experienced notable adversity throughout his 28-year career. I shared with him that sometimes I do not understand my love for this profession. People call me and tell me how badly they’re hurting because of atrocious behaviors within the walls of the firehouse and administrative offices, being skipped over on their third promotional list (without any actionable feedback), having their personal belongings ruined by fellow crewmembers, being attacked on social media, and having their character questioned and reputation destroyed before public city/county commission meetings. From entry-level, day one personnel to the director-level position, no one seems to be immune. I fear for my beloved profession if this course direction remains the same. I don’t know what protective gear can be worn to effectively manage these risks.

One piece of advice this same mentor shared with me over a decade ago, “Be careful what you let in between your ears.” I remind myself of this statement at least weekly. We may also need to reflect on the late-Chief Alan Brunacini’s statement, “Egos eat brains.” Can we get out of our own way to realize how much of a privilege it is to be a contributing member of this industry and treat fellow team members with dignity and respect?

Will we see more personnel complete their annual medical evaluations, follow up for recommended cardiac workups, complete calcium screenings and ensure that all personnel in uniform are following NFPA standards? Will personnel have opportunities to meet their full potential, to leave this industry better than they found it, and work in a healthy, inclusive environment?

We need to consistently care for one another (as we care for the public we serve), collaborate constructively with personnel and city/county management, provide mentorship at all ranks, be a supervisor if that is your responsibility, stop “eating our own,” and communicate effectively, even in times that words are hard and courageous conversations are necessary. If we look others in the eyes when we speak to them, we may remember more clearly that they are also human. Humankind = Human. Kind. Be both.

Know better, do better.

Note: The opinions expressed in this article are those of the author and do not represent any organization. She is sharing from a leadership and organizational health perspective.

Lindsay Judah, DPA, CFO, CTO, currently works as a consultant and previously served as a district chief and paramedic in Florida. She’s an adjunct professor and alumna of Valdosta State University, teaching courses in organizational leadership and public administration. Her doctoral research focused on implementing innovation in the fire service, specifically UAV programs. Judah is an Everyone Goes Home advocate, serves on the Awards and Scholarship Committee for the Florida City County Management Association, and participated on the IFSTA Validation Committee for Chief Officer (5th ed.).