Most firefighters can be cleared the same day as the physical exam. Once the testing, physical exam and one-on-one consultative exam are concluded, if there are no problems, we typically sign off on the clearance letter and give it to the chief at the end of the day. Because most medical providers perform all the testing in one day, they may require up to two weeks in order to sign off on clearance letters. This typically requires that they review the chart all over again once the lab testing is back. Performing a two phase process, where the labs are drawn prior to the exam date, allows providers to sign off on the same day the examination and labs are reviewed. This means that all aspects of the exam are fresh in your mind, and decreases the chance of errors. Also, if the physician has any questions related to the medical chart or test results, he can discuss it in person with the firefighter during their counseling session instead of having to e-mail or call them later.
A typical fire department will have two to five percent of firefighters who will have clearance issues. This may be as simple as needing clarification from their primary care physician due to a medical condition, to something more serious such as an abnormal EKG or Stress Test.
The important thing to remember is that these examinations are not meant to be punitive. The NFPA 1582 Standard clearly spells out disqualifying vs. non disqualifying medical conditions. The key is how well your medical provider knows the NFPA Standard and how well they work with you in dealing with these issues.
Here are some of the more common reasons we see why firefighters may not pass their exam.
Borderline high blood pressure — Based on age, medical and family history, this may or may not present a problem. When in doubt, and if clinically indicated, we offer a temporary (usually two weeks or so) clearance to give the firefighter a chance to follow up with their primary care physician and have this addressed. The important thing here is that they are still allowed to work, and the physician is monitoring the medical condition.
Inappropriate medications — Believe it or not, there are some medications that are contraindicated in the Standard. Typically, they are blood pressure medications, and usually an easy fix. Just have the firefighter follow up with his primary care physician to have the medication changed to another type that is appropriate. Again, depending on the medication and how long they have been taking it, the firefighter is typically allowed to return to work while having this issue addressed. Remember, the Standard is not meant to be punitive, but rather proactive and protective.
Abnormal EKG or Stress Test — This is something that is dependant on the person, medical and family history. If they have a history of an abnormal EKG in the past that has been addressed, and can provide old records, it usually is not a problem.
One big issue is when the doctor doesn’t pass an employee, and the fire chief has to deal with his clearance issues. This typically happens when the medical provider has to hire a doctor for the day, and there is no continuity of care. A good medical provider will follow up with all firefighters who have clearance issues until they are either cleared or permanently not cleared. In our clinic, we always ask that all clearance related information come back directly to the physician who performed the physical exam so we can reevaluate and hopefully clear the employee.
All clearance letters are clearly written with the main issue or issues outlined. We clearly spell out what information we need back from the primary care physician. If there may be any source of confusion, we will copy the relevant pages out of the Standard for the employee to bring to their doctor. Ultimately, we, as the physicians, have final input as to when the employees are cleared. We find that this takes a lot of stress and pressure off of the fire chief, who previously may have had to make that decision on his own.
This is why it is important to find a medical provider that is either physician owned or who has a full time physician on staff familiar with the Standards. We also recommend that you have year round access to the physician who performed the physical exams. You never know when a question may arise regarding a new medication or change in medical condition, and it always helps to run it by your fire department physician.
Departmental statistics are a useful way to monitor the effectiveness of your program. What is included in these statistics? Basically, whatever information the fire chief would like. The one caveat is that these statistics are anonymous. We try to exclude any information that would identify a particular firefighter with medical conditions. Typically, we break down the statistics based on the overall department, and then by decade. It can be interesting to see trends develop in weight, body fat, strength and age.
Some of the more common statistics we provide include age, height, weight, percent body fat, blood pressure, heart rate, total cholesterol levels, triglyceride levels, HDL levels, LDL levels, smoking history, treadmill stress test, leg, arm and hand strength, flexibility, pushups and sit-ups.
Although this technically belongs in Part II Test day, we wanted to briefly mention the benefits of one-on-one counseling. In medicine we often talk about the best way to effect a healthful change in an individual. One of the most effective means is having a physician directly counsel an individual about a health issue. As physicians it is our job to present the information gathered in a manner that is motivating to the fire fighter. We always present the problem(s) and then suggest several possible solutions that are customized toward that individual. We find that this works much better than just a generic packet of information on diet and exercise. Our goal is that the firefighter will walk away from a counseling session empowered to make a positive health change.
We are often asked about HIPPA and privacy issues. Many times firefighters are wary about participation in wellness screenings because they feel that negative health information will be given to their chiefs. We view all testing results as sensitive medical information and treat it as such. Information is only given to the chiefs on a need to know basis and only when there is a potential safety risk. Even in these cases we try to be as non-specific as possible so as to protect the firefighter’s privacy. This is to the advantage of the chief as it takes him or her out of the medical decision making where there is the most potential for liability. We also treat the charts that are generated as part of the yearly testing as we would medical charts in our own offices. Like any good physicians office we strive to uphold confidentiality and privacy standards.
In our next article we will discuss some of the best practices that we have seen in the field for implementing a culture of wellness in fire departments.