This is the third column in a series devoted to addressing the number-one cause of death in firefighters: cardiovascular disease. In the previous column, the high physical exertion endured by firefighters during fire suppression was discussed. It is this high physical stress on firefighters' cardiovascular systems that likely is the cause of the high occupational cardiac mortality rate in firefighters.
Firefighters with underlying cardiovascular disease are at the most risk of dying on the job from cardiovascular disease. Additionally, studies have shown that the presence of major cardiac risk factors in firefighters can be used to predict which firefighters have underlying cardiovascular disease and are at the most risk of sudden cardiac death. In this column, how identifying these firefighters can reduce line-of-duty deaths will be reviewed along with current screening guidelines.
Having a medical screening program aimed at detecting major cardiac risk factors can help detect the firefighters who are at most risk of suffering sudden cardiac death. This is an important concept because it has been shown that controlling the modifiable cardiac risk factors (see our May column) can reduce the overall risk of cardiovascular disease. If firefighters are identified with modifiable cardiac risk factors, effective strategies can be instituted to help reduce their overall risk of sudden cardiac death.
A standard is already in place to help departments develop a medical screening program. In 2000, the National Fire Protection Association (NFPA) Technical Committee on Fire Service Occupational Medical and Health released the NFPA 1582 standard outlining physical screening recommendations to determine fitness for duty for firefighters. Currently, NFPA 1582 is only a recommendation to fire departments and not required since the NFPA is not a government organization, unless your state does adopt NFPA standards as law.
The standard divides medical conditions into two categories. Category A conditions are conditions that could acutely and significantly impair a firefighter during firefighting activities, which would place themselves, their coworkers and/or the public at risk. Category A conditions include visual problems, heart conditions with impaired cardiac function, the presence of a pacemaker, history of seizure activity, and uncontrolled blood pressure or evidence of end-organ damage such as renal disease or retinopathy as a result of uncontrolled blood pressure. Prior history of cardiovascular disease, coronary artery bypass surgery or coronary artery angiography are also Category A conditions. This is important since it has been shown that half of firefighters who died of sudden cardiac death had an established diagnosis of cardiovascular disease.
Category B conditions are those that can possibly lead to acute adverse events impairing one's ability to perform the job safely. Some of the conditions included in this category are asthma, hearing impairment, diabetes mellitus and uncontrolled blood pressure without evidence of end-organ damage. Firefighters being treated for high blood pressure with normalized blood pressure readings do not qualify for either Category A or B criteria.
According to the NFPA, Category A conditions are absolute contraindications to performing firefighting activities. Category B conditions are possible contraindications to performing firefighting activities; however, candidates can be cleared to perform activities after evaluation and medical clearance by a physician. The NFPA 1582 guidelines also recommend that firefighters undergo periodic physical examinations, the frequency of which is determined by age. For firefighters younger than 39 years of age, physical examinations are recommended every two or three years, whereas they are recommended annually for individuals 40 and over.
Limitations of NFPA 1582
Even though the NFPA recommends annual physical exams, as many as 70% of fire departments across the nation do not require or have programs for periodic physical exams. This is mostly based on state occupational safety and health mandates that enforce compliance within their jurisdiction. Additionally, although NFPA 1582 only requires screening for established disease, it makes no requirement regarding cardiac risk factor screening or management. Multiple studies have demonstrated that cardiac risk factors increase over time in firefighters while cardiovascular fitness decreases. Since cardiac risk factors increase over time, having more frequent exams targeted at identifying cardiac risk factors will increase the opportunities to help firefighters reduce their overall risk of cardiovascular disease by controlling identified risk factors.
Reviewing the Risks
To review the important points of this column:
- Controlling modifiable cardiac risk factors can reduce the overall risk cardiovascular disease and sudden cardiac death
- NFPA 1582 is a standard that recommends screening exams periodically based on age
- NFPA 1582 does not make any recommendations on management of cardiac risk factors
- A prior diagnosis of cardiovascular disease is exclusionary criteria to firefighting duties per NFPA 1582
- Cardiac risk factors increase in firefighters over time
- Having more frequent medical exams targeted at identifying cardiac risk factors can increase the opportunities to effectively reduce firefighters' risk of cardiovascular disease
While NFPA 1582 is good reference to being developing a medical screening program to identify firefighters at most risk of cardiovascular disease, cardiac risk factors also must be controlled to reduce line-of-duty cardiac deaths. Our next column will discuss suggestions for developing a program that incorporates medical exams to identify cardiac risk factors and strategies to control those risk factors.
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.