Set? Okay. Good. Good morning, everybody. Welcome to the first public safety medicine session. Second one will follow this. But the first one is we're going to talk about diabetes, seizure disorders, and initial evaluation. Real quick, first of all, for all of you that know me, I'm sorry, I'm Dan Samo, this is all dressed up for you guys, okay? This is not my T-shirt, my Lululemons, and my Orochis anymore. So I hope you all appreciate that I got dressed for you. And so first, Pam Allwise, who is going to be online, but she's been monitoring us. It turns out it's better for the people who are calling in if we show that she's taped her talk. And so it's better for them to show that. So the first thing we're going to do is we're going to show you Pam's video, and then I'm going to do seizures, and then Dr. Fabrice Czarnecki is going to do initial eval, and then at the end we'll do questions and answers. And Pam will be here for questions and answers, too. So roll it. Hi, everyone. I'm Pam Allwise, and I would like to welcome you to our session on law enforcement officer guidelines for diabetes. We try to update these guidelines every few years, and the last ones were done in 2017. And in the last five years, we have had some advances, especially in the technology and some of the medications. So we'll give you an update, and the formal guidelines will eventually appear on the website for the LEO guidelines. I'm just trying to... I'll get rid of the picture in a moment. Okay. So law enforcement officers with well-controlled diabetes are definitely capable of safe and effective job performance. But we know diabetes can have some complications and can affect their ability to perform essential job functions, and certainly the possibility of sudden incapacitation does exist. Therefore, individualized assessment of the LEO is imperative to ensure safe and effective job performance. Now, the LEO guidelines for people with diabetes can also serve as a model for other workers and other occupations, such as EMS, dive teams, or correctional officers. Other businesses have looked for guidelines and have looked at the LEO guidelines as a model. The main point is, match the essential job functions with individualized assessment, and ask, can this person do the job? Now, I thought this was very interesting. This situation occurred pre-LEO guidelines, and Judge Sonia Sotomayor has type 1 diabetes. This is well known, so there's no HIPAA violation here. But in her autobiography, she says that as a girl, she loved Nancy Drew books, and she wanted to be a police detective. At the time, there were blanket bans in some places, and she wasn't sure that she would qualify. So she decided that she would study and go to law school and the rest is history. But I thought that was an interesting situation. I wanted to give you a brief background of the LEO diabetes guidelines. We've been doing them now for over 10 years, and they're based on the American Diabetes Association standard of care. And in the beginning, the American Diabetes Association gave their input because there were some medical legal issues, and there were multiple ADAs, the Americans with Disabilities Act, American Diabetes Association, et cetera. And there had to be a balance between the ability to do the job, there was a history of some blanket bans for certain professions, and also the perceived limitations that people might have had about people with diabetes. So the bottom line was individualized assessment focused on specific complications, specific organ systems, eyes, neuropathy, just like other physical conditions, if a person would have back pain, repetitive motion, injuries, et cetera. The point is individualized system assessment. I want to give you just a brief overview of diabetes in general, the numbers are still going up, we do have an epidemic. We're talking about over 37 million people in the US, that's over 11%. So we're definitely going to have some employees with diabetes. The scary thing is that over 8 million people are walking around with diabetes and don't even know that they have diabetes, especially type 2, and sometimes people already have complications at the time of diagnosis. The other thing is 38% of the adult population have something called pre-diabetes, when the blood sugar is above normal but not in the formal diabetes range. We used to have lots of names for this, pre-diabetes, chemical diabetes, some people used to call it borderline diabetes, but there's nothing borderline about it, it's like being a little pregnant and it is a risk factor for heart disease and for type 2 diabetes. So we want to diagnose and treat. I wanted to go over the types briefly, type 1 diabetes traditionally, people under the age of 20, previously known as juvenile onset, but you can be any age, you can be 5, you can be 75, and the therapy is insulin. For type 2 diabetes, traditionally people are over 40. They have some endogenous insulin secretion, but the insulin is not as efficient as it should be. People can be of any age, we are seeing children with type 2, and we have multiple types of meds for this. We have gestational diabetes, and we also have pre-diabetes as discussed before. I wanted to show the diagnostic tests for diabetes, what's normal, what isn't. A fasting plasma glucose of 126 or higher, or a 2-hour post-glucose with an oral glucose tolerance of 200 or above is diabetes. We usually like to have more than one value, but if you have a person with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose of 200 or above will make the diagnosis as well. For pre-diabetes, a normal fasting sugar is below 100, so a fasting plasma glucose of 100 to 125 would be pre-diabetes. We also talk about an A1c, which is the average blood glucose for the past two to three months. For diabetes, it's 6.5 or above. For pre-diabetes, 5.7 to 6.4. So we want to know what the diagnosis is. Everybody needs a treatment plan, and if you look at the treatment plan based on the American Diabetes Association standards of care, it is very, very similar to the LEO guidelines plan of care as well. It's a lifestyle condition, so people need to have education, and we want them to improve their health by following evidence-based care practices, monitoring blood glucose levels, regular A1c tests to look at control, foot and eye exams, and especially self-management education and support. Papers have shown that DSMES really improves clinical outcomes. Now, we have a rationale behind the treatment plan and behind our goals, and we know that blood glucose management can reduce the risk, especially of microvascular disease such as eye disease and kidney disease, by 40% by keeping glucose levels in a reasonable range. Blood pressure management can reduce the risk of heart disease and stroke. Cholesterol management can reduce cardiovascular complications, and certainly regular eye exams and timely treatment can prevent up to 90% of diabetes-related blindness, foot infections as well. So, when the ADA makes its standards of care and we're evaluating our law enforcement officers, we want to know that our standards are based on outcomes and on evidence-based care. The American Diabetes Association comprehends this medical evaluation. We want to confirm the diagnosis and classify the diabetes, evaluate for complications and comorbid conditions, always review prior treatment, risk-factor control, and develop a plan for continuing care, and when we go to the LAO evaluation, we see it is very close to this. A big thing about any chronic condition is lifestyle and behavioral health, patient education, monitoring, medical nutrition therapy, physical activity, emotional assessment is very important, support needs, and certainly if somebody smokes, smoking cessation as needed. It's a team sport. I would love to see the occupational medicine physician or nurse in this Venn diagram, but we can see that there are many people involved in helping a person with diabetes improve outcomes. What are our goals to prevent complications? Well, we would like the pre-meal glucose to be between 80 and 130, the peak postprandial less than 180. Now, this is for non-pregnant people, okay? The A1c for many non-pregnant adults would be less than 7. However, it depends. If people have other medical problems, maybe we should inch that A1c value perhaps to 8% If people are having hypoglycemic episodes, maybe the blood glucose at bedtime should be 100. It's individualized treatment, individualized assessment, but the overall goal is to have a pre-meal glucose of 80 to 130 and postprandial of less than 180. Let's talk about some tools of the trade. I think the biggest change from 2017 is how much continuous glucose monitoring has become popular and is much more accessible than it had been, but we have lancets and meters and CGM. We have all kinds of insulin delivery tools, syringes, pens, pumps, pads, and we have tools that combine the glucose monitoring and insulin delivery. One of the best websites is the Consumer Guide from ADA, and I've listed the link there. It goes over all of the different products. I love this picture because you can have a whole backpack full of stuff that people will need, but the meters, the insulin pumps, the monitors, aids for insulin users, glucose for hypoglycemia, infusion sets, et cetera. I wanted to go over CGM because definitely in our population it could be very, very helpful. It measures the glucose in interstitial fluid every few minutes. Before we would do the blood glucose levels three to four times a day, and we would see, but it's very helpful in seeing trends in glucose values, and it can identify periods of hypoglycemia, especially during the night. It can show trends by giving you around the clock reading, not just a single number, and it can show glucose levels in the past few minutes and hours and where they may be headed. Another way to look at control is something called time and range with continuous glucose monitors. The time and range for most people would be the range between 70 and 180. Everybody is different, and there has to be a plan with the treating physician, but the goal is that 70% of the time it should be in range. We can also look at the time above range, so we say level one hyperglycemia might be between 181 and 250, and level two would be over 250. We can go on the other end as well, the time below range, because it's a balance. We don't want people too high or too low. If the percentage of readings between 54 and 69 would be level one hypoglycemia, and the percentage of readings below 54, which is the level that we really worry about alertness, et cetera, be level two hypoglycemia. This is very helpful because if we have an average blood glucose, or an A1c, let's say you have an average blood glucose of 150, well, that could be 50 points higher, would be 200, 50 points lower might be 100, but let's say your average sugar is 100. Well, 50 points lower would be 50. On average, sometimes isn't as safe as knowing what's going on. I just wanted to show you a picture of what the report would be, and you can see in the green is kind of what people want, and the CGM will give you a report of the percentage in range, and too high, and too low, and it gives you the 24-hour reading, so it can be very useful. Several years ago, the American Association of Clinical Endocrinologists had a conference, and they said which populations are likely to benefit, and when you look at this list, most of them would be our patients, certainly adults with type 1 diabetes, people who might have hypoglycemia unawareness, insulin-using patients with type 2 diabetes, athletes, physically active people, commercial drivers, heavy equipment operators, and shift workers. So definitely, CGM has come to the fore and can be extremely useful to give us information and then feedback on how to change the dose as needed. I want to go over briefly medications. People with type 1 diabetes, insulin, usually the only treatment. People with type 2 diabetes have many choices, including insulin, but we have many different agents, and we want to pick the agent that has less of a potential for hypoglycemia. So let's start with insulin therapy. What are we trying to do? Our goal is to mimic normal physiology. The normal pancreas puts out a little bit of insulin every hour, and in response to food, we'll have a blip, we'll have a bolus of insulin. We have sub-q insulin that's long-acting, so that would be the basal, and we have bolus insulin, analogs, et cetera, that will work when a person eats. We have various ways of delivering this. For instance, an insulin pump will use short-acting insulin, and the person can regulate the basal and the bolus doses. We also have pods as well. This is just what normal physiologic insulin secretion looks like, and you can see we have the basal, and then in response to food, the body accommodates with a blip of insulin and then comes down, and that's what we're trying to do. Medical therapies for people with type 2 diabetes, we have multiple categories. The sulfonylureas were some of the original medications, but now we have the biguanides. Metformin is usually the first medication to try in somebody, but now we have many different ones. Before, we were only looking at insulin action. Now, we're looking at the other part of the pancreas, the role of glucagon. We have GLP-1 receptor agonists. We have SGLT2 inhibitors. We have DPP-4 inhibitors, and all of these work on how much glucagon there might be, and we have thiazolidine diodes, but the point of this slide is we have so many medications that alone do not cause hypoglycemia. On this list, the sulfonylurea medications are the ones that cause hypoglycemia. If a person is on metformin alone or is on metformin and the GLP-1 receptor agonist, the possibility of hypoglycemia is low, but beware of sulfonylurea combinations because metformin alone, the risk of hypoglycemia is very low, but when you combine the metformin with a sulfonylurea, then we worry about hypoglycemia. That is why I highlighted it. There are so many choices now of medications that are less likely to cause hypoglycemia. This is just a slide to show you there are so many different mechanisms of glucose metabolism, and we have a medication for almost every part of the metabolic chain, from the pancreas to the liver to the peripheral tissues. So now we'll go to the LEO evaluation. As we said before, the educated and motivation LEO with well-managed diabetes can be capable of safe and effective job performance. Individualized assessment should include the following elements, and it looks just like the ADA plan of care. We need to know the history of diabetes and its treatment, how old, how long, presence of complications, and the risk for impairing events. Symptomatic and severe hypoglycemia, hypoglycemia unawareness, symptomatic hyperglycemia as well. Diabetes may affect multiple organ systems, and we have to evaluate each system and each comorbidity to assess the ability to do the job. As you go over each system, look at the specific chapter in the LEO guidelines, like the cardiovascular or the mental health or the vision, because that will help as well. The LEO physician needs to get all the medical records from the treating physician, preferably an endocrinologist, to include date of initial diagnosis, etiology, current medications, current lab values, et cetera. There is a physician evaluation form in the LEO guideline chapter. It looks like this, but it's basically a very useful checkoff list that goes over many of these things. One of the first things we'll talk about is the glucose monitoring. It includes assessment of hyperglycemia, variability of glycemia, and we need meter logs and certainly a continuous glucose monitoring if available. Unwritten or typed logs are not acceptable. We really need to see the data from either the meter or the continuous glucose monitor. Once treatment has stabilized, the glucose log must be available for an LEO with type 1 diabetes for at least a month, for somebody with type 2 who's on insulin, a month, if they're taking sulfonylurea because we worry about hypoglycemia, a month. But if a person is on another type of medication with type 2 diabetes, it really depends on what the treating physician has informed the patient as part of the treatment plan, and it would be good for the police physician and the treating physician to kind of work together to understand how often the person should monitor and how long the records should be looked at. If a person is using a monitor and if they want to know what's going on with a certain job, we want people to do it at different times of the day, especially if they don't have a CGM or if they want to find out immediately. So certainly prior to eating at bedtime, prior to and following exercise, prior to critical tasks, for instance, maybe driving, and if people have any suspected hypoglycemic episodes. There's something called, when a person is hypoglycemic, we have almost like two stages. Sometimes there can be a very fast decrease in the blood glucose. So if a person is going down from 250 to 150 very quickly, they can get an outpouring of all their fight or flight hormones, and they feel like they're having a hypoglycemic episode because their epinephrine, et cetera, is coming out. So they need to check their blood glucose levels. If they get confused they need to check it and that's usually when the glucose level is less than 70. So if somebody thinks that he or she is having a reaction, check the blood glucose. We look at A1c as kind of the report card and that's very useful every two to three months and the average blood glucose may be in a wonderful range, but once again we don't know where sometimes the highs and the lows might be, so continuous glucose monitoring may help. The other thing is if an A1c level is higher than we want, we said that the goal should be seven or less, if it's let's say 8%, this doesn't mean the person is disqualified, but it does mean that perhaps the police physician and treating physician should have a talk and say, hey, how can we look at improving control a little bit to prevent complications, but to prevent hypoglycemia. For the LAO and insulin therapy, we talk about a stable insulin regimen. This means the same types of insulin, basal bolus, insulin pump, or whatever. Now part of the diabetes self-management education is educating a person how to make small changes based on physical activity, food, etc. So that when these are small changes, these changes do not disqualify an applicant under this section, but we would like the regimen to be fairly stable for six months prior to the evaluation. If a person has type 2 diabetes and is on insulin, we'd like a stable medication regimen for about three months. If the person has not been on insulin, probably just a month would be reasonable. If there have been significant changes in dose within the evaluation period, but if there's a new class of medications, especially sulfonylurea, we need to have more frequent checks to see what's going on. The person is on insulin pump, we really need to know when did they start? Did they have any history of insulin site infections, history of pump cessation, pump malfunction? They need to have a backup plan if the pump does not work, and they need to have a plan for sub-q insulin for basal bolus regimen, because it's a machine and things sometimes break. We talked about this before, the medications for LEOs with type 2 diabetes, certainly insulin is part of the plan, and there they run the risk of hypoglycemia. But as we said before, people who are treated with metformin, DPP-4 inhibitors, GLP-1 agonists, etc., the risk is much lower, and I said before, beware of combination drugs with sulfonylurea. The next thing is, how do we look at the complications to make sure that this person is qualified for the job? We'll start with retinopathy. It's a leading cause of new onset blindness and vision loss. We want to complete I&T with an ophthalmologist or optometrist at the time of diagnosis of type 2 diabetes, and five years after the diagnosis of type 1. The reason why we want it at the time of diagnosis of type 2 diabetes is that many people do not know they have diabetes, and they might have had it for five to ten years before diagnosis and may actually have a complication. The one thing about retinopathy that we have to be very aware of, and that's why I highlighted it, is that the LEO with proliferative retinopathy, more than moderate non-proliferative retinopathy, and clinically significant diabetic macular edema should not engage in vigorous physical activity. So that's one of the caveats. We definitely screen for other chronic complications and look at the eye chapter in the LEO chapters. Neuropathy, there's both peripheral and autonomic, and we want the person to be safe. Certainly, if the person has severe pain, paresthesias, or weakness or numbness. If they have ataxia, reduced balance. If they have reduced or decreased proprioception, they might not be able to control the foot pedals, or if they have a history of falls, foot ulceration we need to look for, and also orthostatic hypertension, which could be an indicator of more autonomic neuropathy. Some of the tools of the trade and how to examine, we need a good motor examination, muscle strength and gait testing, vibratory testing with 128 hertz tuning fork, sensation testing, DTRs, position testing, and of course orthostatic blood pressure testing, as we said before, and I put the definition, you want the person to be sitting and then to stand for three minutes. It's a change of 20 millimeters of mercury. It's a very important test to do. The cardiovascular disease, be sure you look at the cardiovascular disease chapter. People with diabetes often have, quote, silent heart disease, and they may not have a traditional angina, so even if the LEO does not have any known cardiac disease, okay, the person should be assessed for cardiovascular disease according to the LEO chapter. If the person does have typical or atypical cardiac symptoms, a formal evaluation by a cardiologist should be done. If a person has a known cardiac disease, further evaluation is needed. Nephropathy, diabetes is a leading cause of end-stage renal disease. Certainly increased albuminuria and decreased GFR are also associated with CBD mortality. The LEOs need to have a serum creatinine, an estimated GFR, and urinary albumin excretion. One of the important things, however, is if the GFR levels are below 45 cc per minute or they have a lot of albuminuria, we worry that the clearance of medications may be decreased and that they have a higher risk of hypoglycemia, especially if they're on insulin or stuff on the areas, so that's why this is highlighted because of the caveat. Certainly, further evaluation is needed if the GFR is low, nephrologist evaluation, exercise stress testing because of the increased risk of cardiovascular disease in people with nephropathy, and we need to have that evaluation. Now, we're going to talk about acute events that could impair the person, and it's hypoglycemia is the most important one. It increases the risk for dysrhythmias, for accidents, for falls, and cognitive dysfunction. Diabetic ketoacidosis is at the other end. Severe hyperglycemia with ketosis, usually in people with type 1 diabetes. Causes can be infection, dehydration. Most of the time, people are hospitalized, and certainly in type 2 diabetes, we can have hyperosmolar, hyperglycemic state, usually associated with infection, sometimes post-operatively, usually needs hospitalization. The definition of hypoglycemia, level 1 is a glucose of less than 70. Level 2 is less than 54, and that's when we see altered mental status, and level 3 is when somebody needs outside assistance to administer carbohydrates, or glucagon, or whatever, and it's a level 3 that we worry about all of them, but especially the level 2s and the level 3s. When we look at somebody who's had severe hyperglycemia, the LEO should be restricted and can be short-term until you find out what's going on, but if the person has had one or more episodes of severe hyperglycemia, and that's when they need outside assistance within the past year, or more than two episodes in the past three years, or since diagnosis, we need to evaluate. What happened? Is there hyperglycemia unawareness? Did the patient miss a dose? Was the activity level much higher, etc.? The LEO may be returned to full duty after the documented analysis has been done, the treatment has been reviewed, and the review of the glucose log for at least one month does not show blood glucose levels below 70 after the medication has been adjusted, so severe hyperglycemia needs to be evaluated. With other types of hyperglycemia, repeated episodes below 70, or one episode of less than 54, these episodes need to be reviewed by the police physician, and again, what happened? Did the person skip a meal? Were they more active? What happened? Short-term restriction may be necessary unless it was an error from the monitor, and once again, check out what happened, get a log, see what happened, and talk to the treating physician, and then if the person has been stable and with no blood glucose levels of less than 70, for at least 14 days, they can go back to full duty. Diabetic ketoacidosis is fairly rare. As we said before, people with type 1 diabetes usually hospitalized. Sometimes it happens if there's an insulin pump malfunction and the person didn't know it, if somebody has missed a dose of insulin, or if they have an infection or major cardiac event, etc. We need to find out what went on, the person's been hospitalized, how has the dose been changed, and once the blood glucose levels are more stable, the person may or may not be able to go to their full duty depending on what the cause was of the DKA. To summarize, we always have to have an ongoing evaluation, and we always have to have our requirements. Because of the nature of diabetes, it's very important that the person have regular medical follow-up, and the LEO will talk to the treating physician and the police physician. The LEO needs to advise the police physician of any change in the type of medication, especially if the addition of insulin or sulfonylurea occurs. Has the person had any symptomatic hypoglycemia, severe hypoglycemia, or even very high blood glucose levels as well? They need to provide documentation if they have any evaluation for cardiac, eye, neurological, or renal disease, and we have a section on chronic complication screening. It was the consensus of the LEO task group that review by the police physician or glucose of the glucose monitoring records and reports should occur at a minimum of every 12 months, but may need to be more frequent in specific cases. Again, individualized. The last slide is I wanted to just bring up some other employer and employee concerns about the worksite. By far, everybody's concern is hypoglycemia, hypoglycemia, hypoglycemia, but the employer and the employees often are concerned about testing logistics, the safety, where are we going to dispose of our supplies, our syringes, or whatever. They are worried about job placement. They are also worried about accommodations if necessary. They're worried about temporary permanent restrictions. They're also worried about their own health status temporary permanent, and the LEO physician can address many of these issues. The references can show you the American Diabetes Association standards of care. They come out every year, and there was also a new one on the management of type 1 diabetes in adults. There's also an abridged version for primary care providers. I thank you very much. If you have any questions, you can email me, and I'd be glad to answer them. Thank you. Am I live? Yes. Thanks, Pam. We're going to hold the questions until the end. One thing I want to point out is that pretty soon you're going to see also a separate document, like the LEO document, because of which we have a new name now. We're not the LEO Task Group. We're the Public Safety Medicine Task Group, because there will be separate documents. Shortly coming out will be for EMS and DIVE, and hopefully quickly followed by ones for correctional officers, SWAT teams, bomb squads. Did I forget any? That's it, and then whatever we come up with next. We run out of time. Now I'd like to talk to you about seizures. The way I'd like to start this, let's see if I got this right, is to give you a case presentation. A 50-year-old male firefighter. One other thing is that for diabetes, this may come up as a question, everything that Pam talked about is really applicable to other safety sensor positions, because the issue about restrictions is really about risk of sudden capacitation, hypoglycemia. That doesn't change depending on your job, so this would be the same for pretty much all of them. This one happens to be a firefighter who had a grand mal seizure in the firehouse, which was witnessed by his co-workers. Unremarkable history. He had normal MRI, EEG, sleep deprived, 24-hour all normal. All his blood and cardiac work was normal, and his neurologist did not start him on any seizure medication. The neurologist then cleared him back to driving seven months post-seizure, and then his primary care doc cleared him back to return to work 13 months after the seizure, at which point he was sent to you with the question is, can he return to work? This is where all the guidelines are back. Remember, these guidelines are about fitness for duty, return to work, disability evaluations. This is a fitness for duty evaluation. I'm going to get the right button here. Again, what's the issue? For all of the fitness for duty things, there's really only two issues. One issue is, are they unable to do the job? Are they physically unable to do the job? The other issue is, is there a risk of sudden capacitation? For seizures, is there any problem, inability to do the job? No. They can do the job. They're fine. There's nothing specifically due to seizures that may affect the job, but you do have to consider what medications they're on, and therefore you go to the medication chapter to see if that's going to impact their ability. The other thing is that you really should think about doing a neuropsychological evaluation. Many people with seizures have neuropsychic issues, cognitive issues, and so you really should check that also. But really, nothing inability. What really is the issue here is risk of sudden incapacitation. With seizure disorders, that's significant. In standarddom, if that's a word, people write standards, the acceptable risk of sudden incapacitation is less than 1% per year greater than the general population. If you have a more than 1% risk of sudden incapacitation in the following year, that's unacceptable. Where did that come from? It's made up. It's made up. There's no science that says, but really what it is, is what does society accept as normal? There are some studies about that where they asked people, they said, okay, so you live by a nuclear power plant. What risk are you willing to accept that you're not going to get cancer? The answer is more like one in a million, one in a hundred thousand. What risk are you willing to accept that the person driving your kid in the school bus is going to have a sudden incapacitation and crash the bus? One in a million. When we say 1% a year, that's one in a hundred, which is very, very generous. Part of that reason is that the risk of a 45 or older male in this country having a sudden cardiac event is probably about 0.4, 0.5%, 0.45%. We accept that. We don't tell every 45-year-old male who's in safety-sensitive positions they can't work. Society has accepted that. That's kind of where the 1% comes from. Certainly, the rate of recurrence for a single unprovoked seizure is high. In the first year, it's 14% to 62%. Also, I don't have all the quotes, but there are dozens of references in the document that you can read all of this stuff, and we have if you want to. Second year, 4% to 19%. Third year, up to 7%. Fourth year, 6%. It's not until the fifth year that it really drops under 1% consistently across all the research. If you have recurrent rates for epilepsy, and epilepsy is two or more seizures more than 24 hours apart, it doesn't drop below 1% until they've been seizure-free for 10 years. This is where all this comes from. The guidance right now, there are so many different types of seizures, and we struggled for a long time to figure out how do we separate this without having something for every different single type of seizure. We finally realized that there's three classes. There's provoked seizures, there's single unprovoked seizures, and there's epilepsy, and there's two or more seizures. The standard now gives you a way to evaluate depending on in which class that they fall. For provoked seizures, just to make sure I haven't forgotten anything, because I don't want to shortchange you. For provoked seizures, there are two types. There's those with low risk for recurrence, and those with the higher risk for recurrence. These are the ones that are low risk for recurrence. Certain medications can give you seizures and toxins, metabolic, hypo, hyper, whatever, sodium, potassium, calcium, you know, eclampsia, withdrawal, especially barbiturates, cocaine, things like that, or less than seven days after head trauma. These are provoked seizures. You know what caused the seizure with a low risk of recurrence. For these, really, it's not about the seizure. It's about the underlying problem. So whatever the underlying issue is, is that you can evaluate that. There may be some other chapter in the document, but once that has resolved, once there's no longer that underlying problem and it's been evaluated, then they can be released. Now, if they're put on seizure medications for whatever reason, then they have to be treated as high risk. Nowadays, most epileptologists, neurologists will not put people on seizure medications just after a first seizure. High risk for recurrence, more than seven days after head trauma, intracranial hemorrhage, brain infection, stroke, surgery, structural lesions, active phase. So these are bad things. And these with high risk of recurrence, even if they only had one seizure and it's provoked, these are treated as if they have epilepsy. So they fall under that classification. The biggest problem that you're going to see is the single unprovoked seizure. Because the neurologist and the family doctor are going to send, and the Epilepsy Foundation, they all say, well, you know, after six weeks, they can go back to driving. Because studies show, this one study out of Arizona showed that people six weeks out didn't have more auto accidents than those who were a year out. Of course, that doesn't mean they didn't have seizures. It just means they didn't have auto accidents. Big difference. But someone who has a single unprovoked seizure, who has a normal MRI, a normal EG, normal labs, can return to work if they're seizure-free for the recent five years on or off medication. Again, most epileptologists are not starting them on medication. And the reason for that is that 50% of people who have a single unprovoked seizure will never have another seizure in their lifetime. That's great. The only problem for us is, I don't know which of those people it is. There is no way to know who's going to have it and who's not. So yes, totally unfair to the 50% who are never going to have another seizure. But you don't know. There's no way to know, at least not at this point. So it's five years on or off medication. If they have an abnormal EG or if they have an abnormal MRI, then they're treated as having epilepsy and comes on to the next classification. I told you that already. So you're going to get a lot of kickback because of this. Doctors say, well, it's 50-50. He's probably not going to have another seizure. That's probably true. He's not going to have another seizure. But you don't know that. And then I always ask the neurologist, OK, would you be OK if this is the guy who drives your kid in a school bus? The answer is usually no. But you don't really care what the neurologist says. Part of this you can understand is, first of all, you all do this. We all do this. We get letters from the doctor. They lie through their teeth that the treating doctors will do what the patient asks. They're the advocate for the patient. Doc, I need to go back to work. I'm not getting paid. I need my bed, whatever it is. Clear me. And they do. Doc, I don't really like my job. I don't want to go back. Tell them I can't work. Fine, you're restricted. I mean, you see it. I see it every single day. And so, yes, you don't have this. This is evidence-based. This is based on the science that we know for the risk of sudden incapacitation. And that's all we care about. So for epilepsy, again, two or more seizures, 24 hours apart. One provoked high-risk seizure, one unproved with abnormal testing. Or diagnosed with any of these syndromes. You can look them up, but these are weird sort of things. Actually, the temporal lobe one is a very common type of seizure. And a lot of them have emotional outbursts and all kinds of emotional or psychological appearing conditions. And these three are actually fairly difficult to treat. Some of them are, the juvenile myoclonic are actually well-controlled with medication, but they fall under seizure. So if they've been well-controlled for 10 years on medication, that's fine. But all of these are treated as epilepsy. So epilepsy can return to work if, when does their risk fall under 1%? If you're watching, 10 years. So seizure-free for 10, the most recent 10 consecutive years. It's not like, oh, I was seizure-free for five years, then I had a seizure, and I've been seizure-free for another five years, so I've been seizure-free for 10 years. No. Consecutive 10 years, that's how it works. That's how it works. That they're on an ongoing regime of anti-epileptic medication, and they have no adverse effects from that medication. Or they're seizure-free, and they're off medication for the most recent consecutive five years. So these come into some of these weird little sort of different diagnoses. So controlled epilepsy is really that it's controlled. And so that means that you're on the medication, and you're on the ongoing, and no bad side effects. So that's called controlled diabetes, and so you fall under that. The other is resolved, and that is either some of these are a little like juvenile syndromes, and so they will not have had, hopefully, seizure for 10 years by the time you see them. And so if they're past the age of that, or again, no seizure for 10 years and off medication for five years, that's called resolved epilepsy. We'd like to give things labels. And I don't, not me personally, but. Anybody who's had surgery for seizures, you treat them as epilepsy. So they, again, need to be seizure-free for 10 years. And these are rare. Some of the ones we talked about do need them, and real severe seizures. So you're not likely to see someone who's had surgery for epilepsy. So now quickly, I want to switch over to the NFPA, the Fire Peoples. I don't know if you're all keeping up with this, but NFPA came out in 2021 with the 2022 version. Go figure. And it still is chapter 6, which is for candidates, and chapter 9, which is for incumbents. And you know they had the category A. I don't know if you remember category A means that you will not be able to perform the essential job functions. Category B, which means you might not be able to. Supposedly, if it's category A, you would not be able to perform the functions, and therefore, you'd be restricted from being a firefighter. So the 2022 version, so chapter 6, which is for candidates, this is what's out there now. Don't worry, I got some cool stuff to tell you in a little bit, which is why you come to these conferences to hear the cool stuff that nobody knows about yet. So you'll see this is very much like our LEO thing. Surprise, surprise, because many of us sit on both committees and we bring stuff. So no seizures for 10 years, unstable regime, or off for five years, it's the same thing. Normal neurological exam, statement from a qualified neurologist, and again, that high risk are treated like epilepsy, high risk provoked. So that's chapter 6 for epilepsy. Chapter 6 for single unprovoked, basically the same thing that we talked about in the LEO guidance. Normal exam, MRI, and a statement. Now, chapter 9 is now, in this version, is the same as chapter 6. This is a huge controversy, and I'll tell you that many of us, the docs, have been saying you can't have different qualifications for a candidate as you do for an incumbent. Because if you need to be able to do this, or can't have risk, or there's tasks you need to be able to do when you come on, and you're doing the same job, then you need to still be doing them as a member. So over time, this has, we've been developing that, but it's getting cooler and I'll tell you about it in a minute. So chapter 9 is pretty much the same as chapter 6, except it does not talk about low risk provoked seizures in this published document. And in the handout, pretty much I've put both of these chapters so you can read it all to your heart's content. But the changes, here's what happened. So FEMA, now you all know FEMA, and I don't know if you know this, but FEMA provides mucho money to fire services, especially to buy equipment and things like that. A lot of money. FEMA and their EEOC division came in and said, hey guys, you can't have a separate set of standards for candidates and incumbents. That's illegal. And if you keep doing that, we're not going to fund fire departments that follow that guidance. That's got their attention. As you might imagine. So we are in the midst of addressing that. And so there will be a, what are they called again? A TIA, yeah. TIA is not a transient ischemic attack. It's a temporary something or other. We're doing this for what, 30 years? I still can't remember that one. I was saying, NFPA's system of working is pretty Byzantine. It's difficult to keep up with. So there's been a lot of work, a lot of time working on this. And I think, my prediction is that when this is all done, chapter 6 and chapter 9 will pretty much be identical. The difference, there's no difference for us. If someone is sent to you and says, are they fit to be a firefighter, we say yes, or they need these following restrictions. We don't say, no, they can't be a firefighter. We say, they need to be restricted. They can't drive an emergency vehicle. They can't work at heights, whatever it might be. It's then up to the agency to decide what to do with that. And there's a big difference in what you do to a candidate that you would do to an incumbent. I don't have to accommodate a candidate as much as I might an incumbent. And so it's really up to the agency, the chief or whoever, to decide what they want to do with the restrictions that we give them. It is not, you will be asked again and again and again, so are you clearing him or not clearing him? No, clearing him, here's the restrictions. I'm giving you restrictions. They'll bug you, they'll bug you. Here's what you tell them, NMJ, not my job. It's your job. You are not the one who's going to decide if they can be accommodated, not your job. So this will be coming. It'll be very interesting. We knew this when we started writing the LAO documents 16 years ago. As you'll notice, there are no two chapters. There's only one medical standard. What the department does with that is up to them. So don't let them push you around. OK, I'm just going to see if I've been over my time or anything. No, not yet. I don't want to cut Fabrice short in all your questions. So how did this apply to all the other professions, safety sensitive, EMS is the same. Because again, this is about risk of sudden capacitation. All of the public safety sensitive jobs, sudden incapacitation is a bad thing. If you're driving the ambulance, if you're about to start intubate someone and you're having a seizure, this is not good. Correctional officers, the same. Dive teams, the same. Imagine, have seizure underwater. Bomb, SWAT, all the same. So these are all the same. So let's go back to this case. I won't read it again, but here's the question. Is he fit? Let's see, I think that's Fabrice and me. We're hiding in these uniforms. So is this person fit to return after 13 months? Who would let him go back? Raise your hands. I couldn't even fool you into it, could I? Why not? Five years, right? Single unprovoked seizure, great workup, 50% chance he'll never have another seizure ever again in his life. He's restricted for five years on or off medications. So, and don't be confused that the 2013 version of the NFPA said that one year off of medication. So if they had had an unprovoked seizure and they had not been put on medication, they were a year post that, they were cleared. Doesn't fit with the science, but that's the way it was back in the 2013 version. And then if they were on medication, they had to wait five years. Doesn't make any sense. But that's what it was. But fortunately, that's been fixed. So thank you for now. This is Lake Michigan, by the way, in the winter, with the reflection of the high-rises onto the lake. Excuse me. And now I'd like to introduce the famous, infamous, and well-known Dr. Fabrice Zarnecki, who is going to talk to you about the initial evaluations of public health. Initial evaluations of public safety workers. I have on the left 10, 15, 10, 20. Yeah. Oh, please, please, don't pull us. Just throw money. You want to get in here? You need the whole thing. Oh, you need that, too. OK, good morning. I'm Fabrice Zarnecki, the chief medical officer for the Transportation Security Administration, US Department of Homeland Security. The rules of engagement, you get to ask questions at the end, but I get to ask you questions now. So you'll see, to keep you more engaged, I might ask you a couple of questions. I did check the app this morning. Our slides are not in the app. At least, they were not in the app earlier this morning. But you have handouts, at least for my handouts. The content of the slides and the websites, the references are all there. I hope you will get the slides later. OK, that's my disclaimer. It's just my opinion. That's not the opinion of the government or any organization that I'm a member of. So let's talk about legal issues first. And I apologize for some of our international attendees, but at least this piece is US-centric. I don't have enough trouble knowing the US rules. So I'm not going to comment on other countries. And obviously, this is not legal advice. I am not a lawyer. And whatever your issue, especially questionnaires or forms, and that is in our document, in the E-Comelio document, we recommend that you get a competent employment attorney to review that. The law changes as well. So as a matter of terminology, there is a difference here in the language you're seeing. And you might hear the word pre-employment exam. And I highly recommend you don't use that word. Because at least in the US, before you do a medical exam, in general, you need to have what's called a tentative job offer or something similar. Now, that's the US system. There is an exception to that, and I want you to use it. So the exception is if you do some type of physical, when I say you, really the employer. If the employer does a physical fitness test before they extend that tentative job offer, the employer, just for their own liability protection, they may want to have some type of medical clearance. And that is allowed. But they are very strict criteria. So as you see, that clearance, you don't do it. That's done by the personal, the treating health care provider. And you, whether you are the ad hoc working for the employer or you the employer, you're not collecting any information except clearance, yes. So you're not asking for medical questions, and you're not collecting medical information. But again, I'll give you the exception to the exception. What you should be doing is if you have any influence on, so the information that is sent to, let me go back, to the personal health care provider, that is the time to give them a warning about what they are clearing their patient to do. So I would tell them, this is what we're going to get them to do. So I mentioned here very quickly that CPAT test. That's a very common test performed by fire departments to assess their applicants. Very common. It's actually licensed by the union, by the IAFF. So it's pretty common. Any of you were in the San Antonio Fire Academy? Because we actually had a CPAT. And to my recollection, let's say we had maybe 30 ACOG members, not a single one of them could complete the CPAT. And I could not. Now, you're young and healthy, and you prepare for it, you'll probably pass. But I would tell them, here is what we're going to get your patient to do. If you have a MEDS level, do it. Usually, fire police, the expectation is 12 EMS. We are leaning toward 10. But this is an employer's decision. And I would tell them, here are the very specific medical conditions that could be a problem. That is the language that we have in the ACOM LEO document. We have a form. Dear doctor, your patient is going to do the test. Here is what we are concerned about. Are you OK with your patient do that? And last legal issue is GINA, the Genetic Information Non-Discrimination Act. The short version, at least for the US, what they tell you is do not ask for the family history. But when you do that post-offer exam, and you have that fire police or EMS candidate, maybe you might find exceptions. Maybe your lawyer could tell you otherwise. But what I get, when you see quotation, that's from the EEOC website, they tell you, basically don't ask for family history. What I'm giving you here, this is the disclaimer that the Department of Justice is using for their own medical forms. So for their candidates, that is the language they're using. So that's why it's the DOJ lawyers. So let's say you want to be an FBI agent, an ATF agent. That's what you'll see on the form. If it's good for them, it's probably good for me. Now, let's talk about the meat now of the actual evaluation. Medical history, we recommend that you be as comprehensive as possible. Let's go back to the legal side for a minute. This is allowed. What the EEOC says is you can ask anything you want, as long as you ask the same for every applicant. You don't discriminate based on, let's say, age. But you can ask exactly the same question. And I'll recommend that you be as comprehensive as possible. This is a question that EEOC actually recommends, and we do it as well. Whatever people answer, I think this is good documentation. So do you anticipate needing any accommodation? And I've seen a lot of people who go through the post-offer exam in the first week. I mean, I had people tell me, hey, I need a dog. No kidding. I need a dog typically for mental health. OK. Did you mention that? Do you need a dog? Why do you need a dog? I mean, you've been to a TSA checkpoint, I think, lately. Hopefully, you haven't seen a screener with a support dog. Now, we have dogs to screen passengers, but not to support the employees. And actually, the dogs say, do not pet. And there is only one TSA employee who is allowed to pet the dogs, the TSA dogs, and that's me. In the medical history form, the one we created at EECOM for the EECOM LEO, we added as many specific conditions that we could be screening for. So you see there are questions on alcohol abuse. There is the short version of the respirator questionnaire for N95. And there are also some questions on sleep disorder. So stuff that's common. And if you have your own program, I would say customize that to your needs. Obviously, the job, the occupation that you are screening for. If you know your population, personal preference, feel free to customize. We found just a few questions that are occupation-specific. And if you find other questions that you want to ask, add them. Let us know if the occupation is different than fire police EMS, add that. But I think this is the time to be asking that fire candidate, you're going to be on top of a roof. Is that OK for you? Why are we asking for claustrophobia? So SCBA, Self-Complained Breathing Apparatus, Think Level A OSHA suit, even worse. Why are we asking for that food item over there? Pepper spray, exactly. First, if you're a police officer in the US, I would say the majority of LEOs, at least in state and municipal agencies and county, carry pepper spray. It works. it's pretty safe, it's pretty common, it's cheap. Now if you go to pepper spray training, probably 50% of agencies will spray you in training. But even if you don't get sprayed in training, if you are in the streets and your colleague is spraying a person they are trying to restrain, I will guarantee that the other officers at the scene will get some side effect. They will also be exposed, there is no question about it. As far as the physical exam, we did the history. What is it that we say at AECOM for LEOs and correctional officers? Do a thorough physical exam, yes we have a form, vision is pretty important, that's the three things we want to do. Regarding color vision, we tell you which one you can use, but the Ishihara is the most common. It's not a perfect test, but we think it's acceptable for LEO and CO, and then we have a hearing test. Here are the recommended routine tests, the tests you should be doing on everybody. You have unlimited funding, then you can certainly do more things, but that's the three we recommend for everybody. For correctional officers, we recommend these additional infectious disease tests, understanding that you probably cannot use these results for fitness or duty. Let's say you have an otherwise healthy candidate who is HIV positive, you can't disqualify just based on the HIV positive. This is for baseline tests, understanding that they are exposed, and you want to make sure that you do not hire them with that. That's assuming you're allowed to do these tests. This is how we want to convey our message to the employer, what Dr. Samuel mentioned as, three letters, N, and the last one, not my job, not my job. I even had a federal attorney even flip it and say, that candidate is clear for everything except one essential job function, which means you, employer, you, HR, you, chief, you get to decide, but it's really not my job to tell you what you do with that candidate. Accommodation, can they accommodate or not? Not my job. But even the cannot perform essential job functions, I would list exactly what is it that they cannot perform. We agree with that. Whether you are a contractor or an employee like me, you don't make that very clear. Immunizations, we recommend a routine adult immunization. Let's go for EMS, the healthcare worker, fire, that's what's in NFPA 1582. I'm just a messenger here. Medical history, the medical exam, as you see, is fairly comprehensive. I will put one caveat to that. In the NFPA document, the place where they have the medical exam for applicant is what's called annex material, which means it is not part of the standard. It is recommended, but it is not required by NFPA. Practically, when I go to NFPA meetings, this is something that comes up every time, if anything, your job is to make sure these things happen, not necessarily do them yourself. We actually have one of our senior members who said that one of his physicians did a breast exam and lost his job because of that. That's the test that NFPA wants to see at baseline. If you do the test and the aerobic capacity is under 12 meds, that is actually a disqualifier. That's the immunizations they recommend. We have 14 minutes for questions. I came in a little late. We'll forgive you this time, but if it happens again, you will be punished. I'm not clear, which is the book that you keep referencing with the different chapters? I'm sorry, which is what? What is the book that you reference when you reference all these different chapters? This is the ACOBS LEO guidance. It's a subscription online document. We expect you to go home, not even go home, right after this is you go and you're going to sign up. Does OEM sell that book? It's not a book. It's online. There's no print version. The website is leoguidance.org. I think the website is on the handout. Hi, Dr. Allwise. Can you hear us? We can't hear you, though. Okay. Can you hear me now? Unmute. Unmute. I am unmuted. Her lips are moving now. Keep trying. Talk, Pam. There's a delay. Still muted. Okay. Let's try it again. It's on the AOHC website. There is a handout with all the references and all the text. Good afternoon, gentlemen, or good morning. Quickly, two quick questions. The commercial driver and the firefighter are obviously two different jobs. How much concordance is there in the insulin diabetes questionnaires? Can you hear me? Still can't hear you, Pam. Pam, if you can type in the chat box. Okay. One minute. Let me go to the other. Sign language? Yeah, right. Okay. I can tell you that we do look. Pam's audio is okay online, not muted. But we can't hear you. Write it down and hold it up to the camera. We do look at other guidances and compare that to what the literature says, whether it's evidence, you know, is there evidence for it. Yeah, I think it's, I don't remember my DOT diabetes thing too well. But it should be the same. It's risk of sudden capacitation. Because there's always somebody that's going to contest it. Well, this guidance says this. Why did you pick that? Ours is best. Okay. Pam, don't worry. This is not your fault. This is the audio in the room. Oh, there she is. We got you. Okay. The CDL guidelines are still in flux. So that's the answer. Okay. Good. And then I think, Dan, this is for you. The issue of Gina and family history. That's for him. It was Pam. Okay. I've had one fallout in my career where I wish I had known about the guy's, you know, family history. But are you aware of any consequences of fallout from not knowing? Yes. Yes, and I have that on my computer. I think it's a nursing home that got sued, and it's several millions. It's not, so litigation for Gina violation. There are a couple cases. It's still a pretty new law, and there are exceptions. I mean, for the employer to know family history, it's typically OSHA compliance, and it's not for pre-offer exams. Let's say, look, you should have an employment lawyer working with you. So adding that disclaimer does protect your back to some degree. I didn't ask because I'm not allowed to ask, so the consequences are not my fault. The general recommendation, the ACOM's recommendation, the Department of Justice, EOC says, in general, you shouldn't do it. Could there be exceptions? Actually, there are exceptions. I am not aware of exceptions to Gina for post-offer exam. The consequences are a couple of millions. One of the quick things is that the three topics we talk about today are in the LEO document and in NFPA already. The next session, those three topics are not. They're pre-publication topics for you, which is, again, why you come to these conferences, so you get the cool stuff ahead of everybody else. Two items. The first one is more just of a clarification point. I've heard two of the speakers refer to the firefighter guidelines as standards, and I just want to point out that, you know, when you get a call from the fire chief and you tell him, this guy, you know, he's restricted because of this, this, and this, and we need more information from his primary doctor, the first thing that fire chief is going to say is, well, Dr. Vega, those are just guidelines. So I just want to clarify that these are guidelines and not standards. Let me give you the language. So if you talk to NFPA, if you look at the book, it has the word standard in it. Like little s, though? Small s or big S? Big S. But according to them. Like OSHA standards? We're talking like OSHA standard? Like DOT standard? No, no, no. And in general, internally they refer to it as voluntary standard. But what NFPA publishes, it's called standards. National electric code. Stuff like that. That's a standard. 1582 is a standard. Now, if you go to the document, chapter 102, at the very beginning, it says this document is, I'm quoting, information and guidance for physician. Why do you think it's there? Because I wrote it. The other thing is, even though NFPA may consider them standards, almost nobody has adapted them as their standards. Not a single fire department, at least represented in the room when we polled, was using NFPA 1582. Several years back I was in West Virginia because West Virginia had adapted them as a standard. I don't think that's still true. So, yes, it is a guidance. But, hey, it's evidence-based medicine. So, yeah, that's your guidance. Second item is actually a question. You know, currently in the military, you know, active duty members get an HIV blood draw every two years. The department I work for right now, it's civilian mariners. And one of the things that we were talking about, we've talked about, you know, could we legally, would it be okay if we implemented a periodic HIV draw for our civilian mariners? Any thoughts? These are not health care workers. They're not nurses. They're not doctors. They're civilian health care workers. We're not doing that now, but we've talked about implementing that. So, first, is it voluntary or is it required? If it is voluntary, you know, either way I'm going to tell you, get a lawyer. If it's voluntary, maybe. But, Chris, it's the military. West Virginia never volunteer, right? If you come to the next session, I'll be talking about ongoing exams. And certainly an FBA says yes for periodic HIV. Sure. Required? Probably not. Again, I'm not a lawyer, but the answer is probably not. Thank you. I don't think you're allowed to do that. I'd be scared. Hi. My name is Ghazala Qazi. In Maryland, cancer causation in firefighter, most of the cancers are considered to be caused by their occupation. And sometimes I am evaluating them for the causation analysis. And should I ask for the family history if, you know, breast cancer related because of the family history or because he's a firefighter for 10 years? This is a pre, you know, post-SOFR exam where G and I apply. So, I would say my main job outside of CSA is to do that, is to do a cancer evaluation, causation evaluation in cancer in firefighters. So, I would say it would be wrong not to ask for family history. Okay. But the other side of causation is if you look at the literature, and there are probably six or eight significantly sized studies, and they come up with different results. Absolutely. And, again, it's not causation. It's association. And the SMRs and the SIRs, the incidence rates and the mortality rates are tiny. It's 1.2. That's a topic for another day. That's a whole different topic, right? And then the last problem is in most places, like in Illinois, it's a law. If your cancer is a type of cancer that might be caused by heat radiation or cancer-causing chemicals, then it is considered duty-related. So, it's irrelevant what we think. No, that doesn't stop litigation. That doesn't stop everybody from litigating. I think you can use both family history and also genetic tests. I mean, I've used genetic testing in different states. They're given to me. Very good. Thank you. Hi. Good morning. So, I'm Mark Goldhagen. I ran the air medical consultation service for the Air Force from 2005 to 2010, and we did a lot of the same stuff with the strokes and seizures. But I wanted to say that we adopted the 1% rule based upon aircraft failure rate and the risk of any part of the aircraft failing was considered by the engineers to be about 1%. So, we adopted the 1% rule because we felt that the pilots of the aircraft should be no more at risk or shouldn't be a risk to mission completion any more than the aircraft. So, that's where the 1% actually did come from. I like that. No, no. We know that. Sorry. No, this is in Chris's document. But that's based on having two pilots. So, if each pilot has a risk of 1%, then that's the same as having an acceptable mechanical failure, which is what? One out of 10,000 to 100,000. Exactly. But that's where the 1% actually did come from. The question I wanted to ask you, though, was what you didn't cover was for induced seizures. So, there's always been this big controversy, someone with a PFO. Okay? If you talk to the cardiologist, if you have a PFO, closing it reduces that risk of having an induced seizure because you had some kind of small emboli float up into the brain. So, therefore, closing it became curing it. The neurologists were saying that they weren't seeing the same thing with that. So, we always had this controversy as to if the person had a seizure for some reason and they had a PFO, was the PFO, and then closing it, would that consider the person having one and done and could go back to duty, or did they still have to wait the five years? So, I was wondering what your thoughts were on that. I mean, personally, I don't know the literature on that issue. The question is, I mean, did the PFO cause the seizure? Was it really the cause of the seizure? How can you prove that? You don't know. Exactly. So, there were studies that were done that looked at rates of seizures after they closed the PFO to assess whether the risk of closing the PFO, what's the five- and ten-year longevity of having more seizures. Did you look more like people who had one provoked seizure, or did it look more like people that had unprovoked seizures? And the data was kind of in between the two. Yeah. And so, I was just wondering if so, when you're doing one of those exams, if the person had the PFO, do you give them the benefit of the doubt it was because of the PFO, and then clear them after, you know, that's been closed and they're back to duty? And I guess that was the question. Yeah. You're rocking a hard spot, right? I have an epideptologist on my speed dial. He's the guy who helped us write the guideline. Hello. Mark Bodo from Seattle. I had this pre-placement physical back from the late 1990s, and this case still bothers me. So, I was in Detroit, and I was doing a pre-placement physical for a gentleman who wanted to work for the city of Detroit as a high-voltage line worker, and he was a type 1 diabetic on insulin. I said, no, I don't think this is a safe job for you or puts yourself at risk and your coworkers at risk. And I said, no. He sued under ADA to the city of Detroit. I never knew how that came out, and it still bugs me. I'm just asking for comments. I think clearly – oh, I'm sorry. Yeah, this is why we started the whole thing with these LAO guidelines, because there were a number of cases like that, okay? And that's why it's system – you know, did he have orthostatic hypotension or something like that? Can you hear or no? We can hear. Okay, all right, because I'm on a delay. So that was one of the things. The high voltage in that specific case, because somebody asked a similar question a few years ago. For instance, we would worry, is the person on a pump, and could that be affected by his job, you know, physically? He's working at a high voltage. Would it interfere with the pump? Things like that, those specific things. Had those been addressed, who knows what the legal action would have been or would not have been. It's one reason why we try to talk with the American Diabetes Association because we want not so much their formal support, but as long as we are trying to follow the ADA guidelines, we are hoping that the legal stuff will decrease. So that was, you know, an individual thing. If you had found something in that patient specifically, osteohypotension or the worry that what he was doing would interfere with the mechanism of his insulin pump or something like that, the outcome might have been different. Do you think I did the right thing? We think so. Well, it depends. I mean, you know the guidance, but this is what they have to do to be okay. Yeah, exactly. I got a lot of flack from the employer because the city of Detroit was riled up. But if he goes through that checklist and he doesn't meet it, then he doesn't meet it. I'm just going to let everybody know, I think our time is up, so they may stop recording. But can we stay here and let them answer questions? Guys back there? I have one question from the online audience, so let me do that. Feel free to leave. We're done with the virtual session. We won't be heard if you leave. We'll be here because the people who talk after us can be pretty nasty. So the online question is, what if you get what legally is called an incidental disclosure of GINA information? I think you can read it. I mean, that's very common. You get notes from medical records. I think you can read it. Can you use it? I would be very careful using the incidental disclosure of GINA information without legal advice. Sorry, I'm cupping out. Get a lawyer. We're not going to listen to you. Okay, I just got informed that we have to throw it. They're throwing us out. So thank everybody, and we'll see you hopefully at the next one when we talk about the stuff you hadn't heard about yet. Thank you. Thank you. Thank you.

public safety medicine

diabetes guidelines

law enforcement officers

continuous glucose monitoring

seizures

risk of sudden incapacitation

evaluation approaches

neuropsychological evaluation

employer concerns

medical evaluations

fitness for duty

legal considerations

evidence-based guidelines