As a physician and as a firefighter, I am keenly aware of the risks common to all who serve in the fire service. Fire commissioners are uniquely responsible for creating the policy for the health and wellness of their firefighters, selecting the medical services that are part of examination, choosing the physicians providing the services, enforcing compliance with the program, monitoring the program and budgeting the funds to support the program. A tough assignment.
Fire commissioners are required to take training to serve as commissioners, but nowhere in the curriculum do they teach the medical issues. How do you create a cost-effective health and wellness program or choose what constitutes a good medical exam? A weak medical program misses opportunities to find disease before it strikes. A good program saves lives.
The most important part of the process is to have a workable policy in place that fulfills the legal and regulatory requirements while at the same time clearly defining the nuts-and-bolts issues to the membership in simple language. It is this policy that allows the firefighters to understand the objectives of the program without intimidation or coercion. The health and wellness policy defines the schedule of examinations, job assignments with their medical classifications level, and how the process gets done.
OSHA Respiratory Standard — Fire physicals were not a homegrown idea by firefighters to help our own. First, the federal government issued a statutory requirement to protect firefighters using respiratory protection called the Occupational Safety and Health Administration (OSHA) 1910.134 respiratory standard. It states that before employees may use any type of respiratory protection, they must have a medical evaluation using a medical questionnaire or an initial medical examination that obtains the same information as the questionnaire.
The OSHA respiratory questionnaire is used by many districts for firefighters to self report any symptoms, conditions or new medical history once yearly. This is an excellent tool to conveniently monitor the health of our members between the medical exams. It does depend on firefighters honestly answering the questionnaire if they truly feel symptoms.
NFPA 1582 Standard — This is only one part of the applicable standards for the medical examinations for the fire service. The fire service mandated physical exams for firefighters as part of the National Fire Protection Association (NFPA) 1582 standard in 1992. It calls for the fire service to fund and implement medical exams consisting of a health history, physical exam by a doctor, physician assistant or licensed nurse practitioner, and include an electrocardiogram and lung-function test. It set the frequency of exam based on each firefighter's age and recommended vaccination for Hepatitis B.
Recently, this standard was adopted by the Department of Homeland Security (DHS)/U.S. Fire Administration (USFA) for all 50 states. Previously, there was a patchwork of compliance with the standards on a state level with some states doing little more than reviewing a screening health questionnaire.
Commissioners must understand that just because a firefighter had a physical does not reduce his or her chance of having a heart attack. Current exams may catalog pre-existing illnesses and find dangerous new conditions such as high blood pressure. We need to set a standard for the physical exams that will assess the cardiac risk factors. Thus far, we have not demanded that the medical team do this as they perform the physical exams on our firefighters. The fire service pays for medical exams, but does not require appropriate screening tools to detect firefighters at risk for heart attacks.
Heart Attacks Are Preventable
The purpose of fire physicals is to help reduce firefighter deaths due to heart attacks. One statistic says it all. Every year, almost half of firefighter line-of-duty deaths are caused by heart attacks. The typical fire physical is inadequate to reduce the number of deaths. Current physicals do not routinely include screening for cardiac risk factors in a structured format. Screening for cardiac risk factors identifies people who have a high risk of heart attack. This allows them to change some aspects of their risk profile such as smoking, diet and exercise to reduce their risk of having a heart attack.
Risk factors for cardiovascular disease should be part of every health screen done for every firefighter during every medical exam. The medical officer must review the OSHA respiratory questionnaire for symptoms of existing heart disease and also offer a separate questionnaire that would identify cardiac risk factors. If firefighters do not know their cholesterol levels, either the department's exam should provide this test or the department's policy should direct the members to return to their own doctors for the test.
The OSHA questionnaire asks the firefighter to report symptoms such as chest discomfort or shortness of breath. If the firefighter is not sure if what he or she is experiencing is chest discomfort, the questionnaire is an opportunity to ask about it. Usually, the examiner will request those answering yes to those symptoms to come in for an exam. This is how we would identify firefighters needing further evaluation. Perhaps the next step would be to refer the members back to their own doctors or to suggest that active firefighting be postponed pending the follow up with their doctors.
All firefighters should have medical exams. Some districts offer fire physicals only to interior qualified firefighters based on their use of respiratory protection or active firefighters such as drivers. Should we offer it to fire police, veteran firefighters with many years of service, and should it include the electrocardiogram and lung function testing?
Every Firefighter Deserves the Best
My opinion is yes. I believe that every firefighter who responds to an alarm needs and deserves to receive a medical exam. One might view the medical exam as a valuable benefit being offered to firefighters in return for their service to the community or an opportunity to access a check-up for those unable to afford medical care. I believe that it can and should be viewed as the gift of life for members. It must be presented as a "how can we keep you fit to fight fires with us" type of physical. Too often, it is presented to members as a negative threat to weed out firefighters if they have a medical problem. We could and should use firefighter physicals as a recruiting and retention tool, not a hammer to drive members away. We need to start a "fit to fight" mentality to replace the "sacrifice ourselves" mentality.
Fire districts have an opportunity to reduce their potential liability if all firefighters are examined for heart disease. The fire service should want every firefighter on the fireground to be screened because there is significant risk to personnel every time we respond to an alarm. The adrenaline of responding can trigger a heart attack. So can directing traffic or doing a fire investigation. Look at the case histories. Fatalities are not only occurring to interior firefighters!
It is also common for interior qualified firefighters to migrate over the years to less strenuous (less physically demanding) assignments such as drivers, fire police or chief officers. While the first expectation is that this may reduce the likelihood of a job-related heart attack, the converse is actually true. The probability of cardiovascular disease increases with age making any fire-related activity more dangerous with time. These assignments come with additional emotional stresses that are every bit as significant as physical stress. Heart attacks account for a higher proportion of deaths among older firefighters, as might be expected. For example, two-thirds of the firefighters over age 50 who died in 2003 died of heart attacks. The youngest heart attack victim was 35 years old.
Fire commissioners must ask themselves why firefighters should want the medical exams. Some do, while others, especially the younger members, regard it as another administrative burden. At least for those under 30, it is required by NFPA every third year. The frequency of the exam is every other year for firefighters 30 to 40 and every year for personnel over 40.
Some firefighters, especially career firefighters, view the medical exam as a potentially career-ending exam if they are found to have a disqualifying condition. There is never a time that a firefighter would not want to know if something is wrong. The truth is that everyone wants to be healthy and find a potentially serious condition before it leads to an early death. This is what medical screening exams want to accomplish. No one wants to disqualify anyone from serving unless it is a question of safety. All people want to be assured that if something is wrong, it will be addressed and they will be helped back to their previous activities.
Fire commissioners have a responsibility to ensure that members do not present a threat to other members of the department, the public we serve or themselves. For example, a firefighter who is struck down suddenly by a disabling heart attack must be rescued by other firefighters during the interior fire attack or search operation. This scenario will stop the fire attack, which may be protecting search teams, and place a huge burden on firefighters engaged in the suppression operation. An alternate scenario assigns a rapid intervention team with rescue and removal of the downed firefighter.
Anyone who has been on the scene of a "firefighter down" call knows how hectic it can be. The entire operation may focus on the firefighter and not the civilians or property we were trying to save. If the firefighter is a driver, sudden illness or death could result in a motor vehicle accident with a fire apparatus with injury to members and the public.
No single medical exam can address every possible medical issue or condition for every firefighter. If any firefighters have eye conditions that are out of my field, I must ask them to get notes from their eye doctors clearing them for duty. I can't do this without the help of their eye doctors. It is the responsibility of the firefighter, if they want to serve, to produce the documentation. If this is a volunteer firefighter, the cost of the eye exam is their responsibility, not the fire district. The fire service cannot and should not be asked to pay for the specialist's care for anyone wanting to volunteer. This is not part of the basic medical exam offered by the fire service, but rather a clearance from a specialist the firefighter needs to bring to the department in order to complete its review. Almost all career firefighters are provided health insurance through their employment and the issue of the cost of medical is removed.
The district's physician protects its interests. Occasionally, firefighters ask that their own physicians do the physical exams or that their jobs' exams be substituted for the department's exam. I do not recommend this since there may be a tendency for one's own doctor to underestimate the rigors for firefighting or to base their opinion on less data than used for the standard OSHA exam.
While that is the simple explanation, fire commissioners need to take a more rigorous look at the reasons. There are three reasons for having all the medical exams done by the department's physician. First, you increase your potential liability since any other doctor does not work for your district. That doctor is not loyal to you, but to the firefighter who is the patient. If that doctor misses something obvious or your firefighter intentionally does not provide accurate symptoms such as having chest pain, your district is stuck with responsibility. Second, will the doctor know what is involved with firefighting? National Institute for Occupational Safety and Health (NIOSH) fatality reports say repeatedly that physician lack of familiarity with firefighting contributes to line-of-duty deaths. Third, will the doctor ask if there is a history of back pain or prior injuries? Your district will be responsible for a new compensation claim when that firefighter files a claim for a new back injury while humping hose. Also, will the firefighter give you access to his or her entire medical record from a personal doctor if you need to review it to find out? I doubt it.
So that is my reasoning. You should ask your fire district's attorney as well. These are relatively new issues, so what we say here will set the standard, but I am sure you should not allow medical exams to be done by anyone other than your own district's physician. I have seen many instances of doctors finding critical health issues when a patient is examined one additional time. Ultimately, it is the fire district and its medical team that takes responsibility for the health and safety of its firefighters.
Next: Setting Policy
RAYMOND BASRI, MD, FACP, is in the private practices of internal medicine and diagnostic cardiology in Middletown, NY. He is a Diplomate of the American Board of Internal Medicine and president of the Mid-Hudson section of the American College of Physicians. Dr. Basri was elected Fellow of the American College of Physicians in 2001. In addition to his private practice, he is clinical assistant professor of medicine at New York Medical College, an 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. Dr. Basri is a 20-year member of the Excelsior Hook and Ladder Company in Middletown and a deputy fire coordinator for Orange County. He is the senior physician of the Disaster Medical Assistance Team (DMAT NY-4) and the chief physician for Health & Safety Specialists in Medicine, which does onsite medical examinations for the fire service, and consultant to FirePhysicals.com. Dr. Basri wishes to acknowledge the assistance of Brad Pinsky, Esq., Ray Maguire, G. Mark Davis and Dr. Jack Ruthberg, MD. Defendable Criteria: Best Practices