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Whether fighting fires, handling medical emergencies or ensuring public safety, first responders spend days and nights looking out for everyone. How should they look out for themselves, and how can the public help?

"We all know the importance of cardiovascular health," said Dr. Denise Smith, a professor of health and human physiological sciences at Skidmore College in Saratoga Springs, New York. "But in public safety personnel, cardiovascular health is an important component both for their personal health and their ability to perform their mission."

Despite the psychological impact of first responders' jobs, "the attitude tends to be 'they take care of everybody else, and the helpers don't need help,'" said Dr. Joel Fay, a psychologist in San Rafael, California. "We need to encourage them to ask for help."

As director of Skidmore's , Smith has focused her research primarily on firefighters, the dangers of their work and the development of methods to mitigate those risks.

Sudden cardiac death is the leading cause of line-of-duty fatalities among U.S. firefighters nearly every year, National Fire Protection Association statistics show. A study of nearly 11,000 firefighters, published last year in the Journal of the ÃÛÑ¿´«Ã½, found the more fires a firefighter fought each year, the higher the risk of developing a type of irregular heartbeat known as atrial fibrillation. AFib increases the risk of blood clots, heart failure and stroke.

Factors behind the statistics could include stress, inhaling smoke and hazardous chemicals, and the physical burden of hauling heavy equipment, Smith said.

All that "is more likely to trigger a cardiovascular event, even if a first responder has the same risk profile as somebody sitting at a desk," said Smith, who added that more research is needed.

Similarly, police officers in the United States have about 30 to 70 times higher risk of sudden cardiac death during stressful situations, such as physical confrontations and pursuits, compared to routine police activities, found a published in the British Medical Journal in 2014.

The psychological challenges that first responders face is even clearer.

Fay, a police officer for 30 years who now counsels first responders, encounters problems ranging from post-traumatic stress disorder and depression to alcoholism and family crises.

"It's been a particularly difficult time for responders," he said. The effects of the COVID-19 pandemic and widespread staffing shortages "have meant a lot of mandated overtime, which means you may have more trauma and less time to bounce back from it."

Fay helped found the , a California-based organization that offers counseling, training and education to first responders and their families, and conducts in-person retreats to help them recover from traumatic incidents.

"Typically, they wait way too long to get help," he said. "It's a macho culture – for women, too. But I think that's changing. Responders are more willing to accept help, and then you have to have the help available."

Fay said he's encouraged by the growth of wellness programs in agencies across the country to support their first responders, and peer support groups among the responders themselves.

"I think that's reducing the stigma," he said. "When a peer tells you that you need to go talk to somebody, that means more than if an outsider says it."

For physical and psychological reasons, the experts' advice is similar: take care of yourself.

For example, research has shown that cardiovascular risk factors such as smoking, high blood pressure and obesity are major factors in sudden cardiac deaths for firefighters, especially as they get older.

"It's especially important that first responders heed the advice that most of us know," said Smith, who co-wrote about firefighting and the heart in the ÃÛÑ¿´«Ã½ journal Circulation in 2017. "Maintain a healthy body weight, an adequate level of fitness, get your rest, eat healthy, get screenings (for health issues)."

The Centers for Disease Control and Prevention offers more to first responders for self-care, including a buddy system to help one another, limiting shifts and workloads, working in teams when possible, and reminding yourself "the needs of survivors are not more important than your own needs and well-being."

Fay advocates exercise – "it makes a difference in how your body processes stress" – and guarding against "unhealthy coping strategies like alcohol abuse."

He also suggests that first responders have a primary care clinician. They don't have to see the clinician very often, Fay said, but "when you do need to call them, they already know who you are, and they can catch up pretty quickly."

As for the rest of us, Fay said, "let them know you appreciate the job they're doing. Knowing their community cares about them means a lot."

Smith certainly agrees, but she has a caveat that she knows might not be popular. With long hours, irregular schedules and frequent interruptions, it's hard enough for firefighters and other first responders to maintain a healthy diet.

"But then people want to come and say thank you for responding, or coming to my children's classroom, or whatever," she said. "That almost always comes in the form of cupcakes and cookies and treats.

"You should see a fire station at Christmastime – it's so well intentioned. But they never bring over things like celery."