This is the last column in a series devoted to addressing the number-one killer in firefighters: heart disease. Previously, we discussed why firefighters are at a higher risk of cardiac death, why firefighters with underlining cardiovascular disease are at the most risk of suffering a cardiac line-of-duty death (LODD), and we reported on obesity in firefighters and increasing awareness of non-specific symptoms of cardiovascular disease.
The presence of cardiac risk factors in firefighters also can be used to predict other cardiovascular diseases such as blocked arteries in the carotid arteries of the neck leading to stroke or in the legs leading to pain and amputations. Earlier, we discussed how identifying firefighters with cardiac risk factors through annual exams and implementing risk-factor reduction strategies can reduce firefighters' overall risk of cardiac death. This column will cover implementing a comprehensive medical program to address all aspects of cardiovascular health.
Annual exams are only one component to a medical program. It is an important first step to identify firefighters at risk and to start medical interventions to help control cardiac risk factors. This will allow firefighters at risk to follow-up with their doctors to monitor their cardiac risk factors and adjust the therapeutic regimens accordingly. Larger departments with occupational physicians may opt to have their firefighters follow up with the department physicians, ensuring continuity of care. This approach ensures that firefighters will receive the follow-up they need.
Smaller departments with fewer resources may recommend that their firefighters see their own doctors for further management of cardiovascular disease risk factors. The individual firefighter must schedule their own doctors' visits and be compliant with risk-factor reduction strategies regardless of who manages the condition. Firefighters must show up for appointments, follow lifestyle recommendations and take their medications as prescribed. Fire department leadership may motivate firefighters to comply with all of the above if the seriousness of non-compliance is conveyed. If you don't follow the plan, you are at higher risk for becoming suddenly incapacitated at a fire. You may be jeopardizing yourself as well as your fellow firefighters.
Volunteer firefighters may only serve if physically fit. There is no legal right to perform firematic duty if not medically qualified. The physically demanding job requirements cannot be ignored and the law says one must be capable of the tasks to participate. Use the information provided in this series of columns to impress on your firefighters the importance of following these recommendations.
A comprehensive medical program includes lifestyle modifications. Lifestyle adjustments are the first step to reducing important cardiac risk factors such as high blood pressure and cholesterol levels. Lifestyle adjustments include eating a heart-healthy diet and performing cardiovascular exercise.
A heart-healthy diet consists of a low-fat, low-sodium diet rich in whole grains, fruits and vegetables. Anyone who has been around the fire service knows that firehouse meals are not always the lightest. However, one study demonstrated that firefighters were unsure of the components of a heart-healthy diet and a majority of the firefighters wanted to know more about it. We recommend having a registered dietitian give a lecture at the firehouse with handouts on heart-healthy diet information as a good first step. The dietitian may critique the current menu and provide sample meal plans to improve the firehouse diet.
Exercise recommendations are 30 minutes of aerobic exercise a minimum of four days a week. Physical inactivity is considered a risk factor for cardiovascular disease. Aerobic exercise is also important for firefighters, since multiple studies have demonstrated that firefighting requires high aerobic conditioning. Overall conditioning and strength training can reduce fireground injuries as well. Departments could install exercise equipment in the firehouse if funds are available. Refurbished equipment may reduce the initial expenses. Some departments approach local fitness centers and ask for special group rates. Donations could also be sought from local fitness centers or exercise equipment retailers. Local media outlets could be contacted about the donations and media coverage could be motivation for business owners to participate.
Lifestyle changes also include quitting tobacco. Tobacco use is a well-known risk factor for cardiovascular disease. Studies have shown that firefighters who smoke are at a higher risk of cardiac LODD. Departments should adopt a zero-tolerance smoking policy while in the firehouse, adjacent property, and firematic events. However, quitting smoking is not easy. It takes the average person seven attempts before succeeding. Very few people are able to stop on the first attempt without medication. Fire departments may assist their members by providing smoking-cessation programs.
The National Fire Protection Association (NFPA) 1582 standard lists a previous diagnosis of cardiovascular disease as a category A condition. Category A conditions are considered conditions that could acutely affect a firefighter during an emergency and jeopardize the safety of the firefighter, other firefighters and the public and are an exclusion criteria for firefighting duties. It is recommended that all fire departments adhere to this component of this guideline. A medical study examining line-of-duty cardiac deaths showed that half of the firefighters examined had a previous diagnosis of cardiovascular disease and, according to NFPA 1582, should not have been in active firefighter roles. While some firefighters may object to this, as it may be career ending, it must be conveyed to them that it is their career or their life.
Additionally medical research suggests that the fire service adopt morbid obesity (defined as body mass index over 40) as a category A condition and prohibit the severely obese from performing active firefighting operations. Often, these individuals are more than 100 pounds over their target body weight. Obesity often occurs with high cholesterol and blood pressure, major cardiac risk factors. Obesity itself is now regarded as a cardiac risk factor. Obesity significantly impairs an individual's ability to perform aerobic work. Aerobic functioning is important for firefighters since many functions normally performed at structure fires require high levels of aerobic activity. All of these factors can severely limit an obese firefighter's ability to perform firefighting functions safely.
Firefighters may resist the efforts of leaders to implement a comprehensive medical program and view such a program as a threat to their careers. Volunteers may see such a program as another burden to the growing mandatory requirements on their time. However, a wellness program can be marketed as a "reward of health" for an individual's service.
Start by explaining that you are trying to keep everyone "fit to fight" for the community. Career firefighters may view such programs as a possible threat to their careers if they are found to have an exclusionary medical condition. However, we must assume that most people would want to know that they have a potentially life-threatening condition. In those situations, continuing to work as a firefighter may unnecessarily place their life at risk. For volunteers, such a program could be marketed as a reward for their service to the community. Another benefit is access to care as many people in this country have no insurance. A medical program would let individuals access screening exams that they may not be able to afford on their own.
A comprehensive medical program can help reduce firefighter line-of-duty deaths and improve the overall health of the members of the fire department. It is up to fire service leaders to be advocates for their members and, ultimately, the public we serve and their members' families to implement medical and wellness programs.
We hope that you use the information we've provided in this series to show your members, commissioners and city managers how extensive the problem of cardiac LODDs is. This same information can be used to justify the fund necessary to implement a health and wellness program for your members.
DR. RAYMOND BASRI, MD, FACP, is in the private practices of internal medicine and diagnostic cardiology in Middletown, NY. Dr. Basri is a Diplomate of the American Board of Internal Medicine and president of the Mid-Hudson Section. He received the 2008 Laureate Award of the American College of Physicians, of which he is a Fellow. Dr. Basri also is clinical assistant professor of medicine at New York Medical College, attending physician in the Department of Internal Medicine at Orange Regional Medical Center and on the consulting staff in cardiology at The Valley Hospital in Ridgewood, NJ. He is a member of the Excelsior Hook and Ladder Company in Middletown and a deputy fire coordinator for Orange County. Dr. Basri is the senior physician of the Disaster Medical Assistance Team (DMAT NY-4). He is a senior aviation medical examiner for the Federal Aviation Administration (FAA) and chief physician for Health & Safety Specialists in Medicine, which does onsite medical examinations for the fire service and consultant to FirePhysicals.com.
ERIC BERGMAN, PA-C, is a physician assistant practicing internal medicine at Hartford Hospital in Hartford, CT. He earned a bachelor of science degree in allied health from the University of Connecticut and a master's degree from Albany Medical College. He is a member of the Killingworth, CT, Volunteer Fire Company; a past company officer and life member of the Avon, CT, Volunteer Fire Department; and a past member of the Shaker Road-Loudonville Fire Department in Colonie, NY.