As a physician and as a firefighter, I am keenly aware of the risks common to all who serve in the fire service. One statistic says it all: Every year, nearly half of the line-of-duty deaths of U.S. firefighters are caused by heart attacks. In 2004, there were 49 heart-related fatalities of 104 U.S. firefighter line-of-duty deaths. Over the last decade, this grim statistic remains unchanged despite the mandate to do fire physicals. The purpose of this article is to provide you with a better understanding of fire physicals and to describe some specific steps you can take to help reduce firefighter deaths due to heart attacks.
Several important questions must preface this discussion:
My training as a physician allows me to reduce the risk of heart attacks for my civilian patients every day. If we apply the same life-saving principles to the fire service, we can directly reduce the number-one cause of firefighter deaths: heart attacks. The fire physical plays a significant role in this process, but currently is inadequate to reduce the number of deaths.
Fortunately, most of the groundwork to reduce deadly heart attacks in the fire service is already in place. So is most of the funding. We already mandate and budget for medical exams for active firefighters. That is part of the solution.
The second phase of the solution is to include specific cardiac risk screening for firefighters. 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.
Firefighters and fire officers must understand that just because a firefighter had a physical does not reduce his or her chance of having a heart attack. Current physicals may catalog pre-existing illnesses and find important new conditions such as high blood pressure. We need to set a standard for the physical exams that puts in place a program for tallying the cardiac risk factors found during this screening.
So far, we have not demanded that the medical team address this issue as it performs the physical exams on our firefighters. The fire service pays for medical exams, but has no requirement that during the physical, appropriate diagnostic screening tools be used that would detect firefighters at risk for heart attacks. However, firefighters continue to die from heart attacks at the same rate as 10 years ago. In fact, in 2003, "There was a sharp increase, however, in heart attack deaths from 37 in 2002 to 47 in 2003." (Full report, Firefighter Fatalities in the U.S. 2003, NFPA, Paul R. Leblanc, June 2004, http://www.dps.state.mn.us/fmarshal/Response/FFFatalities2003.pdf.)
The following questions provide the framework to understanding how cardiac screening could work to save firefighter lives:
HEART ATTACKS DON'T JUST HAPPEN
Heart attacks are one form of cardiovascular disease. Let's take a look at the problem, what it is and how often it strikes Americans.
Cardiovascular disease comprises diseases of the heart, hypertension, congestive heart disease, heart attacks or myocardial infarctions, and strokes, which are like heart attacks in the brain. Cardiovascular disease is a lethal epidemic in the United States. It is the number-one cause of death in the U.S. and it kills more than the next five causes of death combined. Each year, at least 600,000 Americans die of heart attacks and for half the first symptom is death.
These are horrible statistics and the situation is getting worse each year. One in five American men have coronary heart disease before the age of 60. It is reasonable to roughly assume and estimate that one in five firefighters has the same disease! Coronary heart disease can be asymptomatic, without any symptoms, even in its most severe form. One-third of all heart attacks are silent. You or your firefighters may already have had a "silent" heart attack and you may not know it!
Risk factors for coronary heart disease and heart attacks are high blood pressure (hypertension), high cholesterol (hyperlipidemia), elevated blood sugar (diabetes), smoking, being a male, older age, obesity, and family history of a parent or sibling having heart attack, stroke or bypass surgery before the age of 60. Some of these risk factors can be put into an equation to calculate the 10-year cardiac risk for an individual. We can estimate with a fair degree of certainty using risk factors those firefighters most likely to sustain heart attacks in the future. We don't need to wait until our people drop dead on the fireground! For many firefighters, this is their first and last symptom.
Some risk factors of them can be modified, treated or controlled, and some can't. The more risk factors you have, the greater your chance of developing coronary heart disease at a younger age. Also, the greater the level of each risk factor, the greater the risk. For example, a person with a total cholesterol of 300 mg/dL has a greater risk than someone with a total cholesterol of 245 mg/dL, even though everyone with a total cholesterol greater than 240 is considered high-risk.
Fire physicals were not a homegrown idea for firefighters by firefighters to help our own. First, the federal government issued a requirement to protect firefighters using respiratory protection called the Occupational Safety and Health Administration (OSHA) 1910.134 respiratory standard. It states that before an employee may use any type of respiratory protection, he or she 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 departments as a yearly means for firefighters to self report any symptoms, conditions or new medical history. 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.
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; electrocardiogram; and lung function test. It set the frequency of exam based on the firefighters' age and recommended vaccination for hepatitis B.
Since that time, there has been almost universal acceptance of fire physicals for at least some personnel in all departments. However, there has been no scientific study done to evaluate the benefit to the individual firefighter or the fire service. We should consider how to collect data on the reliability of fire physicals and to specifically consider if heart disease is being found before it kills firefighters.
SHOULD ALL FIREFIGHTERS HAVE MEDICAL EXAMS?
Some departments 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?
My opinion is yes. I believe that every firefighter who responds to an alarm needs and deserves to receive a medical exam. One may view the medical exam as a valuable benefit being offered the firefighters in return for their service to the community or an opportunity to access a checkup 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.
The fire service should want every firefighter, regardless of his or her function on the fireground, to be screened, especially for heart disease because there is inherent 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! The fire district and local government share an opportunity to reduce their potential liability if all firefighters are given medical exams and especially if the exam screens for heart disease.
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 may be expected. Two-thirds of the firefighters over age 50 who died on duty in 2003 died of heart attacks. The youngest heart attack victim was 35 years old.
SOME FIREFIGHTERS DON'T WANT FIRE PHYSICALS
Do firefighters 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 every third year. The frequency of the exam is every other year for firefighters ages 30 to 40 and every year for personnel over age 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. I have faced this many times with commercial airline pilots as a senior medical examiner for the FAA. Medical issues with commercial pilots could suddenly end a lucrative career and many years of experience.
There is never a time that either a pilot or 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. My work with pilots has never been hindered by their concern that I would ground them, since anything I find will be the first step to get help and return safely to flying. Then I offer my support to requalify them as fit for duty.
The same is true for the fire service and our members. 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 helped back to their previous activities. It is the responsibility of the fire department's medical program to follow up with these firefighters until they are back to duty.
THIS IS A SIMPLE ISSUE OF SAFETY
Fire districts and our officers have a responsibility to be sure members do not present a threat to other members in the department, the public we serve and even mutual aid companies. For example, when a firefighter is struck down suddenly by a disabling heart attack, other members will have to remove or rescue him or her from 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 is the rapid intervention team is tasked 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 FIRE PHYSICAL CAN FIND EVERY PROBLEM
No single medical exam can address every possible medical issue or condition for which a firefighter may be suffering. When a firefighter has a history of an eye condition that is out of my experience, I must ask them to return with a note from their eye doctor clearing them for duty. I can't do this without the help of the eye doctor.
It is the responsibility of the firefighters, if they want to serve, to produce the documentation. For volunteer firefighters, the cost of the eye exam is their responsibility, not the department's. 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 that the firefighter needs to bring to the department in order to complete its review.
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 a firefighter does not know his or her cholesterol, either the department's exam should provide this test or the department's policy should direct the member to return to their own doctor 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 medical 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 suggest that active firefighting be postponed pending the followup with their doctors.
The mandatory use of a separate questionnaire for cardiac risk factors comes from decades of analyzing who gets heart attacks. There are printed questionnaires, simple calculators and online websites that calculate risk scores based on 10-year risk. Any individual with risk above 10% over the next 10 years should be made aware of the risk factors that could be improved to lower risk such as smoking or high blood pressure. All high-risk individuals should be asked to see their own doctors. The fire service should not exclude these members from serving, but ask that their own doctors ensure their safety and review their situation. The department's medical examiner should not accept any clearance for a member with chest discomfort and a high-risk score that does not include a stress test. Their doctor may find the individual fit to participate in firefighting and reduce the potential liability of the department and municipality.
Occasionally, firefighters ask that their own physician do the physical exam or that their employment medical exam be substituted for the fire 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 an opinion on less data than used for the standard OSHA exam. I also have seen many instances of doctors finding critical health issues when a patient gets examined one additional time. Ultimately, it is the fire service and its medical team that takes responsibility for the health and safety of its firefighters.
FIRE PHYSICALS ARE A GREAT TIME TO DISCUSS GOOD HEALTH
The assessment of an individual's cardiovascular risk factors is an excellent opportunity to counsel the firefighter on the spot. There is no better time to advocate for positive change than when the firefighter has the knowledge in front of them. Simple lifestyle changes can mean lower risk for years to come.
Smoking cessation should be offered individually to every firefighter at the time of their medical exam. The doctor, physician assistant or licensed nurse practitioner must take the opportunity to review the smoking history with each firefighter and use the face-to-face contact to ask them to quit on the spot and to write prescriptions, if necessary.
The fire service should also offer smoking-cessation classes yearly to all members and their families. These classes could be sponsored by the fire service on a countywide level. This is another value-added benefit of membership, which directly helps the firefighter and the department.
I have served as the medical officer for fire departments for 15 years. I believe that a quality medical program for the members should be fully integrated into the department's workflow and training programs. The chief should have a medical officer with some medical training such as an EMT who would be a liaison to the medical team performing the physical exams. This will ease the administrative burden on the chief and ensure the timely scheduling of exams and their completion.
DO THE FIRE PHYSICAL ON SITE
Instead of sending the firefighter to the fire physical, why not send the fire physical to the firefighter? Here is one good solution. I would like to describe our medical program for local departments in the Hudson Valley of New York provided by Health and Safety Specialists at www.firephysical.com. The OSHA respiratory questionnaire is available online and may be completed before the medical team arrives on site.
A team of health professionals brings the medical exams onsite to the firehouse between 6 and 9 P.M. and/or selected Saturday mornings. We set up various required stations within the social hall or truck bays to perform the separate parts of the exam. We ask firefighters to complete the OSHA questionnaire if they have not already done so, and then route the personnel to one of five stations for vision and hearing testing, electrocardiogram, lung function testing, fit testing, and finally to see the doctor or physician assistant. The doctor reviews the OSHA questionnaire with the firefighter individually and a cardiac risk calculation is done. Firefighters are also vaccinated for hepatitis B. While firefighters are waiting, we offer handouts on cardiac health and smoking cessation.
Some departments offer more than the basic services listed above. Some offer to pay for their members to have blood analysis for cholesterol and chemistry, flu and pneumonia vaccinations, and limited stress testing. This last item, stress testing, is a crucial tool in evaluating high-risk individuals. Fire departments spend lots of money on less-than-critical items (chrome wheels for rigs, for example). Why not invest your funds wisely on your most valuable resource, your members?
The medical team goes to the firehouse for the convenience of the members and to help create the environment within department that will continue all year long. We set up follow dates throughout the year to allow departments to stay compliant to the NFPA and OSHA guidelines. If several departments are geographically close, we will offer to see members from adjacent departments while working at another firehouse. This reduces the time delay in starting new members or returning members to duty after illness or injury.
ADDITIONAL STEPS FOR BETTER OUTCOMES
If we are to reduce the numbers of firefighters being killed by heart attacks each year, we must consider executing the following aggressive steps:
- First, the physical exams we provide to our members should be standardized.
The bottom line is this: firefighters must view themselves as athletes who work at maximum emotional and physical stress levels without the advantage of a warmup in a game that is not win or lose, but life and death. As the statistics so painfully show, the deaths are often preventable. We must improve the maintenance on our human machines to insure their reliability and safety.
Dr. Raymond Basri, MD, FACP, is in the private practice of internal medicine and diagnostic cardiology in Middletown, NY. He is a Diplomate of the American Board of Internal Medicine, president of the Mid-Hudson section of the American College of Physicians and a Fellow of the American College of Physicians. In addition, Dr. Basri is an attending physician in the Department of Internal Medicine at Orange Regional Medical Center in Orange County, NY, and on the consulting staff in cardiology at The Valley Hospital in Ridgewood, NJ. He also is an 18-year member of the Excelsior Hook and Ladder Company in Middletown and has been a deputy fire coordinator for Orange County for 10 years. Dr. Basri is the senior physician of the Disaster Medical Assistance Team (DMAT NY-4), part of the Federal Emergency Management Agency (FEMA) and the Department of Homeland Security. He also a senior medical examiner for the Federal Aviation Administration and the chief physician for Health & Safety Specialists, which does onsite medical examinations for the fire service, as well as a consultant to FirePhysical.com. Dr. Basri wishes to acknowledge the assistance of Gordon Wren Jr. (see Forum), Jerry Knapp and Mark Davis in the preparation of this article.