This is the fourth column in an in-depth series devoted to the number-one killer of firefighters each year: heart attacks. Previous columns have established that medical exams targeted at assessing cardiac risk factors could identify the firefighters at most risk. By identifying these firefighters, their risk of cardiovascular disease can be reduced by treating these risk factors.
National Fire Protection Association (NFPA) 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments, can be used as a guideline to develop a medical screening program. In this column, we will discuss how annual physical exams with cardiac risk factor identification and management will help reduce the number of cardiac deaths in firefighters each year.
Currently, NFPA 1582 recommends yearly physical exams for Class A, or interior, firefighters. Multiple studies have shown that cardiac risk factors, including high blood pressure, obesity and cholesterol levels and the incidence of diabetes, increase with age. Annual medical exams for firefighters would increase the opportunities to identify cardiac risk factors and institute appropriate therapies to control them. Physical exams should include blood pressure monitoring and weighing the firefighters to determine their Body Mass Index (BMI). This allows for an accurate assessment of body fat. Some firefighters' medical exams include blood work such as glucose, chemistry and cholesterol. Although the blood tests are not part of the mandated NFPA examination, they add significant information for firefighters who would not otherwise have a complete medical exam with their own doctor. Although the rate of diabetes in firefighters is unknown, it is a widely accepted major cardiac risk factor and annual exams offer an excellent opportunity to screen for this condition.
We can lower the risk of cardiovascular disease by controlling modifiable cardiac risk factors. Annual exams are only the first component to reducing cardiac line-of-duty deaths. The second component is treating risk factors. Annual exams will only identify who is at risk, but cardiac risk factors must be controlled in order to reduce firefighters' risk of cardiovascular disease. This requires instituting lifestyle changes and perhaps medication.
The National Institute for Occupational Health and Safety (NIOSH) recommends that physicians performing physical exams be experienced in the field of occupational medicine and familiar with the physical demands of firefighting to be able to thoroughly assess for risks in firefighters. This is because the physical demands of structural firefighting are unique and so strenuous that the physician's experience with the job makes a crucial difference.
The medical screening program should include a smoking cessation program. Smoking is recognized as a major cardiac risk factor and is detrimental to overall health. Although some career departments have adopted a zero-tolerance policy on tobacco use, this is not universal. Additionally, quitting tobacco use is not easy. One study estimated that it takes an average of seven attempts to quit smoking. Both career and volunteer departments should make smoking cessation policy part of their health and wellness programs. A medical screening program would offer an excellent opportunity to screen for tobacco use and counsel firefighters on the available tobacco cessation methods.
Who Should Be Screened
All firefighters should have yearly medical examinations. Part of every exam should be screening for cardiovascular disease. While interior firefighting operations have the highest risk of cardiac death, responding to and returning from alarms also has a significantly increased risk of cardiac death. For volunteer departments, this includes older members who typically do not perform interior operations such as engineers or fire police members. For career departments, this also applies to chauffeurs and administrative personnel who respond to multiple-alarm fires for support.
Changes are often met with resistance where tradition is a significant part of the culture. Mandating annual physical exams could cause labor disputes when they are seen as a threat to employment by career firefighters if a firefighter is found to be unfit for duty. However, a thorough explanation of why annual physical exams, treating cardiac risk factors and maintaining physical fitness represent benefits the individual firefighter should help with acceptance of such programs. No person, firefighter or otherwise, would knowingly want to risk one's health rather than get good medical care.
Funding is another barrier to implementation of health and fitness programs in career fire departments. Many departments have seen their budgets decrease over the past decades. City governments may choose not to accept recommendations for budgetary reasons. However, having effective medical screening and fitness programs in place can save municipalities money. The City of Los Angeles, CA, had a 25% reduction in worker's compensation costs 14 years after implementing a health and fitness program comprised of annual medical exams, fitness requirements and dietary counseling. The savings for municipalities would extend into retirement periods, as maintaining that firefighter's health throughout their career would cost less in health benefits after the firefighter retires.
The volunteer fire service faces two issues of declining funding and membership. Many volunteer fire department rosters are decreasing across the country as fewer people find the time to devote to volunteering. One possible reason for the declining rate across the country is that there are ever-increasing mandated federal and state training requirements. Some may view mandating physical exams as another burden. However, annual physicals could be given on a drill or meeting night at the firehouse, thus minimizing inconvenience to the members.
Another barrier to initiating medical exams is the lack of adequate funding. Annual physical exams should be used as a volunteer retention reward and promoted to the membership as a benefit. The mandated exams are health maintenance rewards to firefighters for their service to the community. One strategy for encouraging volunteer firefighters to comply with medical programs is to have qualified medical personnel educate volunteer firefighters on the consequences of cardiovascular disease. Furthermore, noncompliance with medical treatment increases their individual risk of heart attacks and may motivate firefighters to be compliant with cardiac risk factor reduction therapies.
The first step to reducing line-of-duty deaths due to cardiovascular disease is to institute a medical screening program with efforts targeted at identifying cardiac risk factors in firefighters. Controlling modifiable cardiac risk factors will reduce the overall risk of cardiovascular disease and with it the risk of heart attacks. Therefore, cardiac risk factor identification during annual exams needs to be coupled with cardiac risk factor management to reduce line-of-duty deaths. Fire service leaders need to use the available information on this topic to promote and establish medical screening programs. Individual firefighters should be counseled on the risks of heart attacks while firefighting and encouraged to work with their own doctors to address cardiovascular risk factors screening and management.
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.