BY SANDY DAVIS
The fire service in the United States and Can-ada has only recently begun to understand the importance of maintaining a healthy workforce. Is that a fair statement? Do you agree or disagree?
If you look at the rationale behind that statement, I trust that you will agree. The ironic fact is that for more than 200 years it has been the duty of fire service personnel to save the lives of the public. However, only in the past 15 years has the fire service become concerned about saving the health of its members. Many of us did not consider how our job affects our health until NFPA 1500, Fire Department Occupational Safety and Health Program-1997, was established. Even when this standard was established, most departments had to be forced into compliance. If I had a nickel for each time I’ve heard the statement, “We can’t meet NFPA 1500 because it will cost us too much money,” I would be wealthy. The truth is that lack of money is no excuse for ignoring the health and welfare of the very people who have the responsibility for saving the lives of others. The real reason most departments have resisted such change is that it is a new concept and, as we are all aware, the fire service is an incredibly traditional institution.
“SMOKE EATING”
If you still do not agree with my opening statement, consider the following. When I first began my career approximately 24 years ago, the average life expectancy for a firefighter was less than 60 years, compared with the 70-year life expectancy of the average American. Do you see something wrong with this picture? I can remember when the hallowed goal of rookie firefighters was to be called a “smoke eater” and to be accepted by those who had already attained that title. It was considered a “rite of passage” for firefighters to see how long they could stay in a smoke-filled structure and then exit and light up a cigarette and get some of that “good smoke.” The old “salt” would drag the rookies in and hold them “at bay” like a coon dog with a prize-winning coon up a tree until they lost their previous meal and then laugh at the probie for not being able to handle it.
I can remember coughing up black, sooty-colored mucus for two or three days after a good working fire. I can also remember that the more I coughed and hacked after a fire, the sooner I would be inducted into the fraternity of the “smoke eaters.” Those of you who have been in the service for at least as long as I have are probably aware of where the term “smoke eater” came from. For those of you who may not know, the term “smoke eater” was very deliberately chosen, as opposed to the term “smoke breather.” It came about because our bodies are designed to know that smoke is bad for our lungs and has a built-in defense mechanism that takes the smoke away from the lungs and into the stomach.
I have lost count of the number of funerals I have attended for my friends and fellow firefighters. Many of those funerals were for firefighters who were too young to die, but they died anyway as a result of heart- and lung-related diseases or cancer. I’ve walked by so many caskets and asked “Why so young?” I know many of you have probably had similar experiences. WAKE UP! It was because of job-related exposure to toxins. With the exception of the September 11 attack last year, it has been statistically proven that more firefighters die from collapse than from any other cause on the incident scene. I’m not talking about building collapse. I’m talking about the collapse of their cardiovascular systems. Are you starting to believe?
A positive note is that most departments now have mandatory personal protective equipment (PPE) guidelines that include the wearing of SCBA at any incident where the potential for smoke inhalation is present. Although this is a positive step in the direction of making firefighter health and safety a priority, it is only a beginning.
MEDICAL SURVEILLANCE PROGRAM
The next step beyond mandatory PPE should be a medical surveillance program. The program should be a precursor to a mandatory fitness program or practical job skills performance evaluations. All members of a department should be given a medical physical before they are required to do physically demanding activities. Did I say “before they are required to do physically demanding activities”? Absolutely! I truly believe that before the new recruit, career or volunteer, is allowed to participate in the first training exercise or to respond to the first incident, the department should have a record of a medical physical evaluation on file for that member.
An occupational physician or an osteopathic physician-someone with specialized training in occupation-related injuries and illnesses-should perform this medical evaluation. Our function as firefighters and emergency medical responders has many unique performance requirements. This physician must be familiar with the performance requirements of the fire service in general as well as any special requirements distinctive to specific departments.
Members should also have medical physicals at regular intervals as long as they continue as a member of a department. Each jurisdiction may choose to establish the interval period. However, guidelines and regulations that spell out how this should be determined should be in place. As an example, some standards suggest that members between the ages of 18 and 29 have a medical examination every three years, members between the ages of 30 and 39 once every two years, and those over age 40 annually.
In addition, the Code of Federal Regulations (CFR) 1910.120 requires that hazardous-materials team members have a physical annually. Also, to receive recertification in some specialty areas, members may have to meet specific medical physical requirements. Ideally, every member should have an annual medical examination. However, if your department finds this impractical, the important thing is that evaluations are done. Although the purpose of these evaluations is to benefit the individual member, the time frame for such examinations should fit any applicable laws and regulations to help protect the department from liability claims.
Having had the opportunity to network with hundreds of safety officers through my association with the Fire Department Safety Officers Association, I am constantly surprised and concerned by the number of departments that do not have any type of medical surveillance program. The old excuse “We can’t afford such programs” continues to plague our profession; I say you can’t afford not to establish such programs. Every department-whether a large metropolitan paid department, a tiny rural volunteer department, or anywhere in between-should make a quality medical surveillance program a priority. Do not let the fact that your department cannot afford a full-time medical director with staff stop you from moving forward with a program.
Most departments start with the basics and, after the values of the program prove themselves worthwhile, implement additions until a complete program is established. Generally, the department members feel that such a program is a great benefit to them personally; however, this is not to say that all members will readily accept such a program. Among the dissenters will be those who believe that the department is implementing the program to try and “weed them out.” Members who have the greatest need for such a program and would benefit the most from it usually exhibit this attitude. This may include older members, members who have poor nutritional habits, and those of the mindset that a medical surveillance program is a physical fitness program.
Although a physical fitness program is important to a department, a medical surveillance program is a completely separate issue. It and a complete fitness and wellness program should be sold separately to the membership.
As with most changes in the fire service, a medical surveillance program must be designed to allow the department’s membership to “buy in.” When my department began mandatory annual medical physicals in 1997, I received phone calls from almost every member whose turn it was to go for the first time. The excuses ran the gamut: “I am too out of shape for a physical.” “I worked too hard yesterday on my day off, and I am too tired today.” “I have had a cold and need to postpone my exam.” These were a few of the most common ones.
Now, only five years later, if I am delinquent in sending out notices, I am inundated with calls from personnel asking why they did not get notices because they know it is time for them to have a physical. They now appreciate the benefit of having a department that will look after their health and welfare.
The greatest fear expressed by members in departments where programs are being implemented across the country is that the department will use this program to get rid of members who cannot pass the examination. In no way should a program be set up so that a member who cannot pass the physical examination will be punished. The only exception to this should be when an incoming member is made a conditional offer for employment or to become a member of a volunteer department. If candidates cannot meet the medical requirements, they may be ineligible for the position until they can successfully complete an examination. In departments where incumbent members are to be tested for the first time, provisions must be made to allow for those who cannot pass the medical physical. These may include, but are not limited to, a light/limited duty program, sick leave, or-as a last resort for those in a paid department-a disability retirement. For volunteer departments, they may include, but are not limited to, light/limited duty or reassignment of duties until such time that the physical can be retaken and successfully completed. I cannot overemphasize that the threat of termination should not be a part of a medical surveillance program. Every member must be given the opportunity to correct any deficiency that may cause the inability to pass a medical examination. Most often, this can be accomplished through diet, exercise, medication, or surgical intervention.
BASIC REQUIREMENTS OF A MEDICAL PHYSICAL
A medical physical should include the following:
- A written history of the member’s past medical conditions, if any. This should also include the history of immediate family members, lifestyle history (eating habits, exercise history, tobacco usage, and alcohol consumption), vital signs, pulse, respirations, blood pressure, and temperature. This allows the physician to better anticipate and interpret information acquired from the remainder of the examination.
- A visual examination and oral interview of the member. This allows the physician to pick up on any dermatological and muscular-skeletal abnormalities that may be present. During this portion of the exam, the physician will often observe speech patterns and verbal comprehension. These may be indicators of abnormal brain functions that are the early warning signs of many chronic diseases.
- An examination of the ears, eyes, nose, mouth, and throat and a visual acuity and peripheral vision test. Most departments require only that a member be able to see 20/30 binocular with or without the aid of corrective lenses. I strongly suggest that both color blindness and depth perception be included in this area of the examination. This suggestion is based on the fact that the greatest number of firefighter injuries and fatalities come from motor vehicle accidents. The ability to distinguish color differentials and acceptable depth perception limits may help to reduce this statistic. Is depth perception important on an incident scene? I believe that if you take the time to think about it, you will agree that it is.
- An audiometry test is conducted to establish the member’s hearing capabilities. Some hearing loss is attributed to the fact that age diminishes the ability to hear different frequency range changes. If a member demonstrates a greater than usual hearing loss during a follow-up examination, the cause should be investigated to see if the loss is related to the workplace so the causal factors can be eliminated. I believe that hearing protection is the PPE component that is used the least in thefire service today. Would you agree? If so, do something about it within your area of authority.
- A check of the pulmonary function. This evaluation indicates the member’s ability to effectively use the oxygen inhaled to allow the vital organs to operate properly. The guideline for this is spelled out in CFR 1910.120 Paragraph F, under “Respiratory Protection Require-ments.” Inadequate pulmonary function capabilities may be an early indicator of chronic lung disease or can simply be the aftermath of a recent cold or flu.
- Diagnostic imaging, electrocardiography, and laboratory tests. Complete blood work and a urinalysis may be required by your department’s guidelines or by the examining physician based on indicators observed during other portions of the evaluation.
ADDED COMPONENTS
In my department, we added what we call “work conditioning” to the physical exam. During this portion of the exam, the member’s strength and flexibility are recorded; this gives us a great baseline indicator should a job-related injury occur. Each member is tested for his ability to lift a predetermined amount of weight to a certain height a given number of times. The weight, height, and number of times are based on the member’s job description. Grip strength is also tested and recorded.
The flexibility test indicates the member’s ability to articulate each body joint based on the total degree of flexibility and extension. These joints include the neck, shoulders, elbows, wrist, back, and knees. This information is recorded and used for comparisons in the case of job-related injuries. It indicates during return-for-duty examinations whether the member is able to function as well post-injury as before the injury.
I recommend that your department require a P.S.A. (prostate specific antigen) test for male members over the age of 40. The American Medical Association recommends this blood test for detecting prostate cancer for all males over the age of 50. However, with the high rate of cancer in our business, I believe we should begin this screening 10 years earlier to catch this potential killer as early as possible and to help ensure that the disease will respond to treatment.
FUNDING
After your department has determined that a medical surveillance program should be instituted, the next question would be how to fund the program. All standards and guidelines of which I am aware require that the employer be responsible for expenses for work-related medical examinations. In addition, members cannot be required to assume other costs associated with these exams. Some of these costs may include being required to take vacation time, use personal sick leave, or miss out on scheduled overtime to have the time off from work assignments to receive job-related medical examinations.
Time for medical examinations should be scheduled during work hours. In a volunteer department, they can be scheduled during a training period when the member would be present anyway so that the physical exam does not interfere with the member’s “paying job.”
The majority of volunteer and career departments do not have the resources to have a full-time medical staff on the payroll to administer these exams, so you should research alternative methods of funding for these programs. This is where “thinking outside of the box” comes in. Could you have fund-raisers dedicated specifically for medical examinations? Could you use a state-funded healthcare facility in your area? Are there potential local business sponsors with an interest in your department’s health and welfare? Is there a local physicians network willing to volunteer the service? Is there an HMO (health maintenance organization) that knows the benefit of preventative examinations vs. major medical costs? Think about it. I am certain that you have untapped resources in your area that can help defer some of the cost associated with this type of program.
SOME SUCCESS STORIES
Following are a few success stories from my personal experiences with our department’s medical surveillance program. First, as I stated earlier in this article, the membership has “bought in” completely and considers this another benefit of working for a department that has a desire to look after their welfare. In that respect, the program is a morale booster. In the five years our department has had this program, more than 30 members have been alerted to the fact that they were in the early stages of a variety of heart diseases and were successfully treated with medication or minor surgical intervention. These are not old men-they are all in their early to mid-40s.
Because of the P.S.A. exam, one of our members was diagnosed with prostate cancer. He had an irregularly high level on his first P.S.A. at age 40. His personal physician decided to ignore this issue on the first test. The following year, the level had reached an alarming rate; further testing was recommended. This round of tests showed that he had prostate cancer. He had to have major surgery. This member thanks me every time he sees me for requiring this test be run on all members at age 40. He is convinced he would never have caught this illness in the early stages.
These success stories continue to motivate me to come to work: I know that pulling a brother or sister firefighter from a burning building is not the only way we can save their lives and send our members home safely to their families.
SANDY DAVIS is the chief safety officer and a 24-year veteran of the Shreveport (LA) Fire Department. He is the western director of the Fire Department Safety Officers Association and an FDIC instructor and has written for fire service publications.
