No, you probably don't yet. Excuse me. The public safety task group is creating a course for providers, public safety medical providers. And the reason for creating this course is we've been getting a lot of requests from chiefs, fire chiefs, police chiefs, CO, correctional officer organizations. They want to know, so how do I find someone who knows what they're doing? Good question. And so we said, well, how about we create a course and people who complete the course will get a certificate of completion. And once they get a certificate of completion, they go on a website. And you can go on the website, put in your zip code, and we'll tell you who's within 10 miles, you know how that works, 10, 20 miles. So that will happen. It's probably going to happen in the next six to nine months, we hope. And you'll be able to do it all online in your t-shirt and your Lululemons, which I'm not in today. So that's coming, the certificate course. Today we're going to do three things. These are all new topics. They're not anything that's published yet. The first is COPD. Dr. Arnold has taped it. He's in France and might join us, but we're not sure. So we taped them. And then I'm going to do transgender gender diverse as a new chapter that we're getting close to have finished. And then Dr. Zarnecki is going to do ongoing evaluations. So if we can run the tape. Guy's back there. Hello, hello. Hello in the back. Run the old French guy. Good morning. I'm Chris Arnold. I'm coming to you from afar. Unfortunately, I'm not able to be with you in Salt Lake City. I was really missing this. It would have been my first live conference since COVID. And unfortunately, family obligations have kept me from joining. I may be able to be with you by teleconference at the time of the presentation. However, I'm not able to be with you because of COVID-19. So I'm not able to be with you. I'm not able to be with you. I'm not able to be with you. I'm not able to be with you. I'm not able to be with you. I'm not able to be with you. I'm not able to be with you. I'm not able to be with you. I'm not able to be with you. I'm not able to be with you. I'm not able to be with you. I'm not able to be with you. I'm not able to be with you. I'm not able to be with you. I'm not able to be with you. I'm not able to be with you. I'm not able to be with you. I'm not able to be with you. I'm not able to be with you. I'm not able to be with you. I'm not able to be with you. I'm not able to be with you. I'm not able to be with you. I'm not able to be with you. I'm not able to be with you. I'm not able to be with you. I'm not able to be with you. I'm not able to be with you. I'm not able to be with you. I'm a member of the public safety medicine task group. I'm one of the founding members of this group. I'm also one of the early members of the public safety medicine section. And I have 20-some years of experience as the physician for a major metropolitan law enforcement agency, as well as consulting with other agencies around the country. So without further ado, I should let you know that I only have a couple of yachts, a couple of planes, and two chalets. No, seriously, I really have nothing to disclose. I have not capitalized on the medical gravy train. So let's go forward. So we're going to today spend a little time first talking about the material that's in our appendices to these guides, because that gives the foundations for understanding how we're going to then go about evaluating persons. The background of COPD and asthma will be discussed. Then following that, we'll talk about job tests, simulation testing, the foundations for our evaluation paradigms. And then we'll go through the actual guidances in a compressed format that you'll see shortly, and then some special statements about specific work groups and how they vary from each other in terms of doing the evaluations. A key concept in this is all that the public safety practitioners, medical practitioners, are not the persons who are going to be diagnosing the disorders. These are the people who are going to be evaluating somebody for the job. The person is likely to come in reporting a history of asthma or COPD, particularly if it's a candidate for the job. If it's an incumbent, then they may be in for an annual exam or a repeat exam or for an examination for some special services team or in some way having a medical evaluation that this comes up. Or the last case scenario would be that somebody is sent in for the job with a question of, is it asthma or COPD that is causing them to have difficulties? But even in that case, it is not the role of the public safety healthcare practitioner to do the diagnostic workup. Background on asthma is basically to say that asthma guidance in the general medical world comes under two groups that have taken on this task. One is the expert panel of the National Asthma Education and Prevention Program of the National Heart, Lung, and Blood Institute. This was created in the early 1990s and began developing reports on asthma and management of asthma starting in the mid-90s. And ultimately, the last of these that was published as a full report was in 2007. Since then, there have been a number of updates, primarily on different treatment updates as new treatments have become available or as better understanding has become available about different subtypes of asthma, referred to often now as phenotypes of asthma. And however, for our uses, the 2007 report is the best one in terms of, and nothing has changed since then, in terms of the paradigm used for classifying the degrees of asthma severity. GINA is another group that provides guidance for evaluation and management of asthma. This is the Global Initiative on Asthma. And this was developed also by the National Heart, Lung, and Blood Institution, this time in conjunction with the World Health Organization, with a lot of its focus being on asthma management and evaluation in developing countries. The GINA guides come out on a yearly basis with updates. But what they don't do and what they don't offer for our purposes is as clear a guidance or as clear a paradigm for classifying subjects, patients, candidates, as does the expert panel report. The GINA paradigm uses the same criteria. They simply express it differently and don't offer it in a tabular form. The EPR classifications categories come out to be well-controlled, not well-controlled, and very poorly controlled, something that we can work with very easily for setting up guidelines. Hence, we've decided to follow the EPR3 paradigm. This is based on this set here of information and two major categories of classification. One is the level of impairment, which is the baseline and background difficulties somebody's having with the asthma on a day-to-day basis, as well as what they classify as the risk category, and that is basically risk of exacerbations occurring. First, though, we'll talk about the background side, which is largely based on the concept of people have less than two episodes of symptoms in a week, less than two days of nighttime awakening or nights of nighttime awakening per month, and less than two times use of short-acting beta agonists or symptoms per week. This represents being well-controlled along with a reported lack of interference in normal daily routine activities and a peak flow measured to be greater than 80% of predicted or a personal best of, excuse me, an FEV1 greater than 80% of predicted or a peak flow greater than 80% of the patient or candidate's personal best. In addition, the EPR recommends using one of several questionnaires for how much is this impacting the person, how much is this affecting a person on a daily basis? And for this, we find some difficulty for the setting of a job-related exam since the veracity of answers, quite frankly, may not be 100% when a job is on the line. If this is information that was gathered through a primary care or treating physician or these examinations or these questionnaires done at a time when the person was not looking for a job, that may be perfectly reasonable to use. The second category or the second parameter for evaluate persons is the risk, and that is based on whether they've had more than one episode of severity of a severe exacerbation where they were required to take oral steroids. And if they have had more than one in the last year, then they automatically are either not well controlled or very poorly controlled. Word on exacerbations that multiple studies have demonstrated that an exacerbation is a harbinger of more exacerbations. So the more someone has had exacerbations or the more severe the exacerbations, the more likely they are to have recurrent exacerbations. There is no clean number to get people in the categories that we use, try to use for our guidelines of a 1% annual risk. However, for somebody who really meets the well-controlled criteria, including zero to one episodes of exacerbations in the last year, the risk is probably less than 1% of having an exacerbation at work, and particularly, again, if they're not having baseline impairment, likely to be having difficulty with work setting or with work requirements of the category of the professions we're looking at. Exercise-induced asthma is another phenomenon that we're confronted with very frequently. This is no longer considered best to be called exercise-induced asthma because there really are two categories of persons. The American Academy of Allergy Asthma and Immunology has promulgated this primarily, though other authors have also brought this up, that there are clearly persons who have no baseline evidence of asthma, either by spirometry or by symptom sets, outside of the times that they are performing exercise and develop bronchospasm, not just shortness of breath, but demonstrable bronchospasm based on the change in FEV1 related to their exercise episodes. This is not of great significance for our classifications or for our evaluations. In both settings, the treatment plans promulgated are that the persons, if they cannot, for one reason or another, and I'll go over those in a moment, use short-acting bradyagonists, that their treatment be shifted to inhaled corticosteroids and, if necessary, to leukotrienes. The problem with relying on the short-acting bradyagonists is primarily in persons who are engaged in repeat physical activity, either within a day or over several days. Whether they're using short-acting or long-acting bradyagonists, both of these can lead to acclimatization or to resistance of the asthma, and that develops fairly quickly, meaning over just a few days, even to the point that these are decreasingly effective and just to the point that they become non-effective. The risk with persons who are engaged in repeat episodes of exercise in the same day or even over several days is that of tachyphylaxis if they are taking higher doses or repeated doses of either long-acting or short-acting bradyagonists. Obviously, in professions such as law enforcement or corrections officers using short-acting bradyagonists prior to engagement with physical activity is just not practical most of the time because the physical activity is unannounced. Hence, we recommend that anybody involved in either of these two professions try to be re-managed with inhaled steroids and then go through our evaluation process. The asthma categories that we then utilize are those of EPR3 for the well-controlled, not well-controlled, very poorly controlled. We add in that of people who have on-job performance issues and are sent in for evaluation and then obviously exercise-induced bronchospasm, bronchoconstriction. COPD is now our next topic and that is to show that COPD primarily at the beginning is not just emphysema. In fact, it's not really emphysema at all, I guess is the best way of saying it, on a clinical basis. The Global Initiative for Chronic Obstructive Lung Disease, GOLD for short, is another commission that was put together between the NLHBI and WHO, again in the 1990s, to both raise the awareness of COPD and to improve internationally the diagnosis and treatment of COPD. Internationally, it's a huge problem. In the United States, death related to COPD is one of the top causes of death, the top five causes of death, depending on the year. The GOLD Initiative is recognized by pulmonologists as being essentially the gold standard for treatment recommendations and diagnosis, evaluation, classification, and treatment recommendations. GOLD sees COPD as being defined by chronic bronchitis with cough on a daily basis over three months in two consecutive years and relegates emphysema to a pathological component of COPD, or not something that can be used as a part of the clinical paradigm because, first off, the evidence on clinical evaluation of true emphysema and emphysematous changes is often not present until the disease is more advanced, not present, that is, on techniques that we would typically be using, a simple chest X-ray, for example. Asthma is the other component that is a part of the COPD diagnosis, and that is largely by the baseline definition of asthma as airway inflammation and bronchoirritability to lead to bronchoconstriction as being another component of COPD. GOLD talks about evaluating and classifying COPD in a multidimensional aspect, first using that of airway restriction and having four classifications of airway flow, air flow restriction in terms of looking for fixed FEV1 reduction, fixed meaning that the person is treated with a short-acting beta agonist prior to an exercise test, has a spirometry, gets a short-acting beta agonist, performs an exercise test, or does not perform an exercise test, excuse me, in this setting, and is then retested and shows no change or minimum change in their FEV1, suggesting that it's fixed airway obstruction or air flow obstruction. There are then two other characteristics that are looked at for classification. One is the risk of exacerbations based much like in asthma on prior experience of risk crossed over with the symptom burden based, again, on questionnaires, much like in the asthma paradigm. Something to always remember in looking at evaluations of COPD is that it is not at all rare that people with reduced FEV1 may have fairly decent exercise capability. The converse can as well be true, that someone with poor exercise capability may have a reasonable or minimal loss of FEV1. However, in those settings, one needs to certainly question, is this a true COPD phenomenon or is this deconditioning? And the person may need to have true laboratory testing with more advanced pulmonary function evaluation during exercise to see if it's fitness or if it's respiratory in terms of their basis of inability to perform at certain levels. Again, here's the paradigm for COPD evaluation by gold. We look at first FEV1, and I'm not going to go through all of this. All of this is in the appendices of our guidelines. So I just want to show it to you here that it can get complicated in terms of each one of these percent predicted loss of FEV1 has to be crossed with one of these four letters based on how often someone has had exacerbations and what they've answered in terms of questionnaires about the impact of their symptoms on their life in general. This leads up to 16 different categorizations, which is really not valid or not workable for developing the guidelines. We have hence simplified it to really follow the four categories here based on the FEV1. At the same time, the evaluating physicians or practitioners need to be aware of the secondary components in terms of how this fits into the final assessment of the person's categorization. This may or may not need to be done by the public safety practitioner. However, the public safety practitioner should be versed in this so that if they're conversing with a treating physician, they can ask the treating physician to then classify the person into one of these categories so that they can then help decide how to best proceed in terms of evaluating the employee. The CVD categorizations that we then decided to use are mild, moderate, severe, and very severe based on the airflow obstruction, and then the category obviously as with asthma of people who are referred in because of job-related issues. The common factor in all of these evaluations is going to be functional status. Can the person do their job? The only way to do that, that we can think of to assess that, is through job task simulation testing. Remember, job tasks are what make up job functions. So the administrative functions of the job are broken down into tasks, whether it's lifting, pushing, pulling, et cetera. The job may say the EMS guy has to make it to the scene in a reasonable time to help the victims. There are no timed tests for any of these people for their job performances in job descriptions in general. In the setting we're talking about, we would be encouraging agencies to develop job task simulation testing as a way of evaluating persons. We do not expect that every public safety medicine practitioner who's in a private practice somewhere is going to have a gym someplace where they developed a set of tests. They may work with a local physical therapy group and develop tests. Law enforcement is the one group that has had some formal evaluation of job tasks done by one group of a cardiac rehabilitation service in Dallas that has gone through with law enforcement personnel from the area, different tasks that are core tasks of the job and looked at setting up an obstacle course, if you wish, in their rehabilitation facility where they can put the people through these sets of activities. In addition to the physically performing the activities, these are timed and the activities involve ones that are strenuous with the idea that law enforcement personnel probably have to function at a level of 12 nets when they're doing many of their critical job functions. This would be true probably also for corrections officers at the peak of their activities where they'd be into been involved in struggles for EMS and EMS personnel based on comparing their job tasks to those of a set of job tasks for which met equivalents have been promulgated. It was first set out by Eadsworth in the 1980s. We at the task group have felt that EMS personnel should probably be able to function at a level of 10 nets. For dive team members, we're still working on this as this group is not yet published and is still in the pipeline. There are many factors here that are different from these other groups. So we'll have to keep you posted later on the actual numbers for this. The evaluation cycles themselves, again, now come up with the person comes in, says, I've got asthma, I've got COPD. The public safety medicine practitioner said, well, how bad is it? Goes through a few questions to figure out if they can, how to classify the person. If they classify them as well controlled or mild COPD, then we simply would send them on to a job task simulation testing. If they pass this, they can be cleared to full duty with no restrictions. If they don't pass it, then they need to be sent to the treating physician with a request for evaluation and perhaps change in treatment plan. And I would recommend that the person's, that the practitioner send them to the primary care treating physician with some statement about needing to pass this job task simulation testing so that the practitioner has an idea of what they're really trying to work with their patient for. This really helps a lot in my experience, rather than simply send the person to go get cleaned up and come back. Once the person is cleaned up, so to speak, and sent back by their practitioner, then the public safety practitioner would review this decision. And if they're in agreement with it, send them back to job task simulation testing. If they clear, if they pass them, they can be cleared to full duty. Again, if they don't pass back to their treating physician or another note, and the cycle can repeat as many times as the agency policy will allow it. Once the person does clear, or the feature that they have to clear is the job task simulation testing. Nobody can get to full duty without passing the job task simulation testing. For mild COPD and well-controlled asthma, our task group feels that these people can be followed up in a year. For the persons who have not well-controlled asthma or moderate COPD, in these settings, once again, we would send people to job task simulation testing. However, we would also at the same time send them for a consultation with their treating physician, telling them, look, you know, you've got some problems. You really, even if you make it through the job task simulation testing, you really should go see your own doc and check out what's going on. If these people do clear the test, then they can be cleared to full duty. No job restrictions. If they don't clear the test or don't make it through the test, then the same cycle, they need to be referred back to their doc. If they've already gone one time, they need to be referred back, and then can come back, redo the test again until they pass the test as many times as the agency will allow them to do it. Once again, they must pass the job task simulation testing to be cleared back to full, to clear to full duty with no job restrictions. And for these people, in terms of follow-up, six months to a year, depending on the case, is, seems reasonable. For very poorly controlled asthma, severe and very severe COPD, these people are people who are probably been being hidden by the rest of the team so that they weren't known about until something happened or for some reason, if they're candidates, that they are really dreaming of a career. And these people need to be not cleared, sent to the docs for improving their management as much as possible with advice of what they're up against in terms of the job task simulation testing. If their docs do clear them to do the job task simulation testing, then we can send them for that. If they make it through it, then fine, they should be cleared to full duty. If they don't make it through it, then once again, the same sequence, back to their treating physician, check out the condition, try to improve their management. If they come back, we can recycle them again and again, as many times as the agency policy would like, once again, or would permit. However, once again, they need to pass the job simulation testing for clearance to full duty. These people, if they do clear to full duty, they really ought to be followed in three to six months, just for depending on the circumstances of their individual setting. Now, as you can imagine, there's a lot of tension between police and corrections officer with their jobs of having to react immediately to a potentially high physical level of activity. These people are in one category of settings, particularly for that of the exercise induced bronchospasm, bronchoconstriction, which is something they diagnosed prior to their activity. So they really need to be people with this condition who are in police or in law enforcement or corrections office, and really need to be referred back to their docs for reconsideration of their baseline treatment programs, with the idea of primarily turning to inhaled steroids. For the EMS and DIVE population, if they have mild asthma, but they need pre-exercise, short-acting beta agonists, by all means, as long as they have controlled timing so they can do this with the adequate 15 to 20 minutes prior to activities, following the short-acting beta agonist inhaler, then they can use it. For the persons referred in from the job site with questions of job related, or job dysfunction due to asthma or EMS or asthma or COPD, these people need to be sent to their docs, put on modified duties, sent to their docs, and then once they're cleared, come back and do the job test, stimulation testing, then they can be cleared to work if they pass. For DIVE teams, this is really the major difference in the group, is these people are working underwater, they're breathing cool, dry air out of a compressed air tank, they have an increased work of breathing, they have increased work of activity in terms of the work they're gonna do underwater, they're in adverse conditions of currents, of low visibility, et cetera. The U.S. has very little in the way of recommendations for management or for clearing these people. These British agencies have gone into this much more around the diving world of petroleum diving platforms. And basically, as you see here, people who are free of asthma symptoms or have normal spirometry and normal FEV1, FEVC, and have a negative exercise test, meaning no loss of FEV1 after exercise, with cool, dry air, can probably be cleared as long as they're not on extremely high doses of steroids or if they're not taking, as long as they're not taking leukotrienes. This chapter is still in development, and this will come out sometime in the next few months, but this is going to be the paradigm of this, and we will develop a job task simulation testing advice for this as well. Thank you for your attention. Hopefully I'll be with you in a video conference at the time of the meeting. If not, my colleagues will answer any questions you may have and do enjoy Salt Lake City. It's a wonderful city and wonderful colleagues, wonderful time spent together. Take care all. And again, my severe, sincere regret to not be able to be with you and sharing this. Take care all. Thank you, Chris. So now we're going to move on to the next topic, which is about transgender and gender diverse persons, public safety medicine. So that's the, if you read the, when the chapter comes out, it's called TGD, Transgender Gender Diverse. So, oh wait, let me, Chicago. This is the famous, what's called skyscape, cityscape, but everybody calls it the bean. Doesn't look like a bean. So why do we create this chapter? And actually, a couple of things. First of all, we've had many questions from our subscribers, from the LEO subscribers, and it's obviously, everything I talk about applies not only to LEO, but to police, but fire and dive and SWAT and COs and everything. So we may say LEO because it's going to first come out in the LEO chapter, but it really is everywhere. And this is really an area where I think a lot of physicians have, there's a lack of knowledge and an increasingly visible topic in society and in healthcare. And the other thing was, you know, we have an oath. And let me just read this to you here. Hippocratic Oath. Of course, you know, there's 62,000 versions of the Hippocratic Oath, but this is one of them. It says, into whoever's house I enter, I will enter to help the sick, sort of echoing here, and I will abstain from all intentional wrongdoing and harm, especially from abusing the bodies of man or woman, bond or free. And whatsoever I shall see or hear in the course of my profession, as well as outside my profession, in my intercourse with men, if it be what should not be published abroad, I will never divulge holding such thing to be holy secrets. The thing that I think we all have to remember is that we are doing a fitness for duty evaluation on a person. This is not political. This is not about which bathroom you use. This is not about what sports you participate in. This is about, can you do the job? And we need to do that for everybody in a fair, compassionate way, in an environment where all of our patients feel safe. And I think, as I go through this, you're gonna understand that that's really the bigger issue rather than any medical questions. The chapter starts with saying, there really aren't any real significant issues with being transgender or gender diverse that'll affect your ability to do the job. Couple of little things, and we'll get to those. So I put together a team, and actually, first thing I found out is there's an organization called TCOPS, which is the Transgender Community of Police and Sheriffs. And they have several hundreds, hundreds, or a thousand members of transgender, gender diverse police officers, nationally and internationally. These are the executive directors. There are a couple. Julie is male to female. Patrick is female to male. And their assistance in making this chapter has just been invaluable. The other person I involved was Lisa Simons. Lisa is an adolescent pediatrician who is at Lurie Children's Hospital in Chicago. There is a large transgender program, and Lisa is one of the physicians that works in it, and so she's been able to provide a lot of good medical input. Mike Bricker is a psychologist, and he is, I think he's gonna be the director of, he's on the board of the Police Psychological Service for the International Association of Chiefs of Police. And he's written extensive appendix for us about the behavioral health issues of this topic. Then there's this, I found him on the street, and he followed me home, and my wife said I could keep him. So, you know, I couldn't keep the puppy, though. We're not allowed to have puppies in our building, so that was probably why. And then me. So that's the team that's been writing this chapter, this new chapter. So what's in the document? First of all, it's an introduction. And as I said, we're using the term transgender gender diverse, TGD, throughout the topic. And that's a very broad topic. It's inclusive, not just gender, but all the gender diverse, and there's a thousand different things. And there was actually one article that Julie sent us about I can't even begin to explain what people identify as their gender as space, as chocolate chip cookies. I mean, it's unbelievable. So there's a lot of diversity. According to TCOP's data, there are 6,000 known TGG LEOs, 3,600 of them in the United States that are known. And imagine how many are not known. Obviously this is a difficult situation for many of these people. But again, very few fitness for duty issues surrounding TGD. So for pre-placement and periodic exams, I would say that physical fitness standards are defined by the job and not by the gender. So again, it doesn't matter if you're male or female, if you're trans or gender diverse, the job, you have to be able to do the job. And that's what we're there for. We're doing a fitness for duty. That's our job. And in the appendix, it talks about, for the exams, about non-threatening exams and a lot of examples of what you can do to make your office not threatening. For screening and surveillance programs, there really are very few exist for LEOs. For firefighters, there are more, as you know, that they're more into wellness. In LEOs, it's mostly gonna be about lead and hearing. But really, it's no different for TGD officers or any other worker. Wellness programs, you'll get the well thing, okay? You should, I mean, you know, I spend a lot of time finding these pictures for you guys, you know? So for wellness programs, again, no difference. Cancer screening, which is what a lot of these programs are based on, is organ-based. So yes, if I still have a uterus, I have to worry that I have cervical cancer. If I still have a prostate, I have to worry about prostate cancer. So yes, you do need to know what organs a TGD person still has. Some have, you know, and even FTM, female to male, who've had radical mastectomies, I still recommend doing a breast exam because they get perioral cancers, and so you should be checking for that. Now, this is a big point, the physical effects of transitioning. So there's certain, so transitioning can involve, it can be at all kinds of levels. It can be without any intervention, means no medication, no surgeries, and basically just changing your attire, your makeup, your hair, things like that, and how you present to society. It may be medication alone, it may be surgery alone, and it may be both. And depending on what's done, it's gonna change your, it may change your body habitus. So as Patrick would say, he says, I used to have 38 double Ds. So when I had my mastectomy, the whole way I held my weapon to shoot changed. My whole body habitus changed, and so I had to retrain myself how to shoot my weapon to be able to qualify with my weapon. So qualifying with a weapon could be one big thing, but the upper body strength changes tremendously. When you go male to female, you lose a lot of upper body strength. And in firefighting, there's always a big deal between male and female firefighters, is that female firefighters had a lot of difficulty accomplishing certain of the job tasks because of lack of upper body strength. So as you transition, and again, vice versa, as you go from female to male and start testosterone, you're gonna gain upper body strength. So, and overall strength and endurance. And I gotta share this with you guys. So one day we're doing one of our Zoom calls, and we're talking about psychological things. And so I said, well, you know, women have a lot of chatter going on in their heads. Men don't get it, right? We all, the guys all know it, the women, you don't know it, but we don't get it. And Patrick said, well, yeah, but you know, once I started on testosterone, that went away. I went, what? You're kidding me. And so I'm telling this to my wife, and she says, well, what about Julie? When she transitioned from male to female, did she get it? So we had, two days ago, we were going, we're having a meeting here with them. And I said, Julie, she says, oh yeah, when I started on estrogen and stuff, I got all this chatter all of a sudden. I was like, oh my God. It was just stunning. I mean, the stuff you learn about us is just amazing. So anyway, but that's not a physical effect. We have a large table in the document, we will, which is about time to heal. And it lists, I think, 18 of the most common, or 19 something common types of surgeries that might be done, both for male to female, female to male, and gives you an approximate return to work time. I mean, like you would after a hernia surgery, or any kind of surgery, there's gonna be healing time. Just a guideline, it's not absolute or anything, just so you have an idea that this is gonna be four to six weeks, this is gonna be four to six months, just to help you understand what's going on. Medications, and so there will be feminizing hormones and masculinizing hormones. Feminizing, there's a whole list of them. Feminizing, masculinizing is pretty much testosterone. Usually no restrictions based on that. And if there's any questions, Fabrice, who is the mother of the medication chapters, made sure that all of those are in the medication chapter as well, so you can go to the medication chapter to see what's going on. Now the behavioral health stuff is a big section in here. And it's here mostly for education. And indeed, this whole chapter is mostly for education, for educating us about this topic, and so that we can provide compassionate care and do fitness for duty evaluations. So transgender TGD is not a medical or psychological condition, and it is not in the DSM as such. The mental health needs of TGD individuals as well as non-TGD individuals widely vary. You don't have to be TGD to be depressed, to be suicidal, to be anxious, to be psychotic. I mean, that happens regardless of your gender. And so that should be dealt with. And we have a mental health chapter, and you can deal with it as that. Now, TGD people experience tremendous discrimination, marginalization, abuse, physical and psychological abuse. And so there's trauma, there's harassment, their suicidality rate is off the hook. So there are lots of psychological issues in TGD people. So it's not something you want to ignore. And so you need to be aware that they are, can be a problem. Gender dysphoria, and I think the important point here and what the TCOPS people tell us is that not every transgender person or TGD person has gender dysphoria. To have gender dysphoria means that it's interfering, that your anxiety or dysphoria, whatever you want to call it, is interfering with major bio life. It interferes with your life. It interferes with the occupation. It interferes with your life in general. And so it is real. And that is in the DSM. So gender dysphoria is a real psychological condition. Some people never have it. Some people have it. And when they transition, it gets better. It goes away. And some people have it continuously. And so again, something that you deal with as a psychological condition. We have a whole bunch of appendices. You all get that, the appendix? OK. You've got to appreciate, again, the work that I put through to do this. And I want to talk to you a little bit about each of them. Am I still on time here? Yeah, I'm good. OK. God forbid I take Fabrice's time, and he beats me up because he's much younger. So Appendix A is just a glossary. We're putting that together. And it's just so many terms that it's probably useful to you. The other problem is that this whole topic is changing daily. I mean, it's different every time we meet. There's something new or something different. B is medical stuff. And this talks about gender-affirming care, as talked about in there, about promoting a person's right to explore their gender in a safe and comfortable way. Again, I think that's our job, is not to be critical or judgmental. It's just to do what we need to do. The setting needs to be safe. And this whole talk's about what you do. And I'm sure a lot of you, I know in my institution, there's all kinds of things built into the EMR about pronouns and behavioral things. And so that's good stuff to do. Organizational policies for best practices. And the appendix has lots and lots of examples about what you might want to look for in your own organization and your own office. Medications and their intended side effects is included in this appendix. The surgical treatments in there, wellness screening, and sexual and reproductive health, because that continues on. C is the behavioral health. It's huge. I mean, it's huge. And Michael did an amazing job with his team from the psychology section, IACP, putting this together for us. But it talks about, I'm not going to get into the details, but there's so much in there about gender dysphoria, suicidality, depression, anxiety, substance abuse, violence and abuse, issues for providers regarding barriers and other factors affecting care, psychological issues when transitioning while in the workplace, and defining some key terms. Appendix D is going to be legal things. We haven't really started that one yet. And then there's two cool ones. And one of them is E. It's personal statements. So we ask TCOPs to send out to their members and ask them to write in and send us example of their interaction with the health care system, with their medical providers. And so there is about a dozen of them in there. And I'm going to just read you a quick one from a district attorney investigator in Monterey, California. Happens that this is Julie's. As part of a conditional job offer, I was sent to a local health care provider that does pre-employment medical examinations. There are a great many problems with my experience, but one that stands out most was that I had spent about an hour completing a medical history form prior to my visit, where I was asking great detail about my gender confirmation, surgery, and related medical treatment. The nurse came into the exam room and went through the medical history with me page by page. At the end of the interview, he walked out of the room, closed the door, and stated loud enough for me to hear, the tranny in room four is ready to see you. Doctor came into the exam room moments later and was cold and put off. She was curt, required me to go through a series of additional tests, which she was later unable to explain or justify. Another doctor was provided with the same original information. She examined me and approved me for duty without reservation. I felt that the extra tests were ordered and were punitive because I was transgender. The tranny reference was a slur and derogatory. These terms have no place in a professional or social setting, in my opinion. Medical professionals, including office staff, should have a level of cultural competence and understanding that the words are important and that they can be empowering and also demeaning. These terms were demeaning and certainly detracted from my experience, leaving me fearful of contacts with the medical profession for a time. You know, bad commentary on us. So there are several other, there's a dozen or so from different people that are in there. And they're all pretty similar, although some had very, very good experiences. And those are in there, too. The other is grooming standards, working on that. But it's talking about uniforms and ballistic vests and things and, you know, outfitting them and how that changes as you change. And then G is other policies. And really, that's just going to be links to other organizations. So the Endocrine Society, the AMA, the College of Obstetrics and Gynecology, several others, and what their policy statements are about TGD. And then last is, we're going to have to retitle this one. And I'm open to suggestions. We're still looking for a good title for this. But this is dumb questions. And these, so again, we asked the TGD policing community is to send us things that they have been asked or that have been said to them so that we can, and it's a lot of them. And we talked about cutting it back, but I thought they're all short and quick. And I thought that this, more than anything, gives you a sense of what these people are going through. And I got just a couple that I'm going to read to you, a few. This was comments from male to females. So you were a guy, and now you're a girl. Does that make you gay? Now whenever I read one of these, think about, is this something you would ask a cisgender person? And if not, why are you feeling it's OK to ask this of a transgender, gender diverse, or gay person? You did not give birth to your children. Why do you want them to call you mom? Aren't you ashamed of yourself for being transgender? These are things that have been told to people at work. Do you still go to church, or have they thrown you out of church yet? And so from female to male, you know that you will never be a real man. So do you go on a transplant waiting list or something to get stuff from dead guys for your surgery? You have kids. What do they call you? What does their, quote, real dad think about that? And then for some non-binary ones, so are you both? Like your top half is girl, and your bottom half is boy? Or do you like women or men or both? Or does it change from day to day? Or how does that work? And lastly, is this like a trial thing where you just try out both sides to see which one you like best? I thought this was good just to, I mean, it gives you a real sense of the psychological trauma and the discrimination and the harassment that people go through. And that I don't think that we, as medical professionals and providers, should in any way ever be part of that. And next, thank you. And next, the ever-entertaining Dr. Czarnecki. Thank you, Dr. Samo. It's a pleasure. OK. So let's talk about periodic exams. For the people who were not here during the previous meeting, I'm Fabrice Czarnecki, the Chief Medical Officer for the Transportation Security Administration. Here are my disclaimers. These are my opinions, not the opinion of the government, ACOM, and FPA. And I want to talk about the rules of engagement. They're the same as the previous session. You don't get to have a discussion during the session. You don't get to ask me questions until the end. But I get to ask you questions to keep you engaged and awake. And this is not legal advice. Get a competent employment attorney. That said, here you are going to see a couple quotes that come from the EOC website currently on the app. At least last time I checked, they don't have our slides. But they have PDF handouts that have all the links and all the text from the slides. So here is what EOC says. EOC says, in general, you cannot do periodic exams. But if it is public safety, it is actually allowed. And so you'll see some of the specific statement they have. See, they talk about vision tests and electrocardiograms. You see the HIV test. That one is not job-related. In general, the key word you have in what you're allowed to do to current employees is job-related and consistent with business necessity. Get a lawyer to tell you whether what you're doing meets these criteria. This is not a medical issue. And even within our group, we don't necessarily have a full agreement on that. You see here, they talk to you about blood pressure and stress tests for stroke. And by the way, that tells you that the lawyers who wrote that probably should get medical advice. So we're the docs. We should get legal advice. But cops, firefighters, EMS, yes, it's OK to do these ongoing medical exams. And the GINA warning is the same as the one I gave you earlier today. Better not to ask questions about family history. And if you want to get there, do yourself a favor. Get a competent legal opinion. And yes, if you have any interest, email me. I can send you actual case law that did not go very well for the employer when they or their medical providers ask for family history. So let's see what we say at ECOM for LEOs and correctional officers. And please understand, this is pre-publication. That was already peer-reviewed. But it's still probably a couple months away from publication. So first for immunizations, LEOs, law enforcement officers and correctional officers, same immunization as the healthy adults with no specific occupation. Now, let's talk about the surveillance. And you have multiple issues here to go over. The first one is respirators. Now, obviously, it depends what your officers are wearing, are using. I would say most LEOs probably are or should be clear to use N95. If you work in a correction setting, it's fairly common to be issued a full-face respirator. Be aware of that and make sure your surveillance meets whatever they say. Now, the medical evaluation per the OSHA standard 1910.134 does not have a frequency. We'll talk about frequency in a minute. But there is a frequency, as you can see, on the fit testing and the training. Then you have that weird standard called HAZWOPER, which does not apply to most LEOs. But it will apply consistently to, so I'm asking you. Within law enforcement, who gets HAZWOPER exams? Who falls under the HAZWOPER exam? That's a good one. So Klan labs. The one that falls under it by statute, so 100% of the time, is the bomb text. That is a requirement. It's a Department of Justice requirement. Now, the tactical, the SWAT, I think it used to be very common. And I would argue that the Klan labs, that's a subtype of a subset of SWAT. But SWAT, I think you'll see a lot of SWAT officers who have to meet that standard. I think it is decreasing, but it used to be pretty common. Now, what's interesting is that standard has a frequency built in. And they tell you it's an annual medical exam. And the less the physician or health care provider decides, and they can decrease the frequency of medical exams up to every two years. So that's a big deal. If your officers fall under the HAZWOPER, that's a major requirement. OK, then you have the hearing and lead. So among your officers, among your population, who should get these two programs? Farmer's instructors, exactly. Farmer's instructors. Now, for the hearing standard, if you're not a farmer's instructor, I really don't know. I think that's a determination you have to make. Now, what was that? So if you use that thing called lead, I'm making a digression here. But I strongly recommend that you advocate for your employees. I don't think there is a valid reason, at least in the US, to use lead in police training today. And I've dealt with agencies. I say, but the ballistics are different. And eventually, I think most people are changing. There is certainly a cost factor of using lead-free ammunition. But the benefits, I think, should be part of the cost calculation. I mean, I personally don't see a reason to use lead, whether in training or even in the field. And I think as a public safety medicine, our docs, I think we should advocate for lead-free ammunition. Which means no lead-testing program anymore. And then for TB, that's an ACOM recommendation. For correctional officers, we recommend an annual surveillance. Now, let's talk about the content of the exam. See anything here? So that might surprise some of you. But basically, that's what we say. So once a year, get a medical questionnaire. What the document currently says is use the same questionnaire as the one for the initial evaluation. But I'd mentioned earlier, you can only do something that's job-related and consistent with business necessity, which is a legal concept. So whatever questionnaire you are going to use, get that competent employment attorney to review it. And then, do the blood pressure. But unless you have a good reason, at least the consensus of our task group at ACOM is you don't need to do anything else annually. Every couple of years, do an eye exam. Currently, we recommend every five years. It may be more frequently if there are reasons to do it. For everything else, follow the US Preventive Services Task Force. Now, you see the yellow highlight? That means I'm asking you the question. So when would you do a more, what would be the reason to do a more frequent medical exam? All we do here is a blood pressure every year. There's actually no medical exam. So when would you recommend a medical exam? Besides the Haswell standard. Dr. Samuels? Diabetes. Specific diagnosis. Now, medical history has changed. And there may be some indicator on that medical history that requires an exam. So the big ones we have listed, we thought about that are currently in the ACOM document are diabetes, high blood pressure, coronary artery disease. And there might be also conditions where we're looking at chronic kidney disease. Our chapter is almost done, where you as the ad hoc, you want an annual report. You want to make sure that your officer is seeing a nephrologist and gives you a pretty extensive report once a year. You don't actually have to see the officer, but you have to see that annual report with all of the information you're asking. EMS, it's following LEO because it's the same authors. There are small differences. The immunizations are for health care workers. For the respirator, pretty much everybody in EMS should be screened for an N95. Uncommonly, you have EMS providers who do tactical medicine or who are on the entry team with the fire department. Full face respirator, SCBA. So get them the appropriate fit testing, but also that's where we recommend a spirometry. And I don't think we agree on the frequency of the spirometry. I don't think we agree on the frequency of the respirator. I don't think we agree on the frequency of the spirometry yet. Same. Now, why would you put an EMS provider in a hearing conservation program? Sirens. That's one good reason. Give me one more. Helicopter. Aircraft, yeah, definitely, especially helicopters, yes. Know what they do. Really know what your people do. Now, TB surveillance is nice. We have a CDC website. You go there, and as you know, they made some changes on health care workers. But unknown to me, there is actually an annual requirement for something. Do you know what is the actual annual requirement for? And Dr. Gelled, you're not allowed to answer. So what is it that, according to CDC, health care workers, including EMS providers, have to do or get once a year because of TB? Nope. Training. So education is the word on the website. So you don't get them to do a TB test, a questionnaire. Again, that's according to the CDC. Depending on your environment or if you have good reason, you can recommend whatever you want to your employer, but there is an annual requirement for education, for TB education. I did not know that. No, the content is the same. Same as CLEO, do the annual blood pressure and the annual questionnaire. The vision is the same. Here, I spelled out the major condition that will make you get an actual medical exam at a specific frequency. Now, let's talk about firefighters. That's a little bit more exciting. So first, immunizations, they're listed by NFPA. Then they tell you the surveillance programs, type of respirators. If you're a firefighter, you're going to be wearing an SCBA. NFPA is not totally clear, but my reading is they are putting every firefighter in the Hazelwood standard. The standard itself does not add anything to the current NFPA requirements. And they also put everybody in a hearing conservation program. Now, when do you get to do that occupational medical evaluation, which is very comprehensive? So you do that supposedly following every occupational exposure. And I have no idea what that is. Now, there is a separate NFPS standard that's not out yet. It's 1585. That is about exposures. And I know we had heated debates on what is an exposure. So I think by the time that comes out. But does that mean every time there is a fire, you have to do it again? You have to say it's a pretty comprehensive exam. And that's something we might need to bring back to NFPA. But at least once a year, you do the comprehensive exam. Okay, that's the basic. We all do that. The labs, it's every year after age 40. TB testing, I think, once a year, okay? So far, nothing out of the ordinary. Now, that's where it becomes a little bit more interesting. Now, do you see all that cancer screening? And as a member of the NFPA committee, I'm not allowed to interpret the standard. But a very common question we get, so we state internally, is who does that and who pays for it? And the common, I would say, the common answer, maybe the consensus within the group is, as long as we, the OCDoc, we make, we ensure that the screening occurs, it doesn't matter who does it. There is a strong pushback among the docs in the group that we don't want to be involved in that. And as I mentioned previously, one of the largest fire departments in the country had a doc who did a breast exam on a firefighter, and he got fired. Okay, then you get even more unusual things, which is sometimes explained in the annex of NFPA. So for sleep, they mention the Berlin and the Epworth as possible tools you could use. For the psych at the bottom, they give you a lot of possible tools to use. I mean, read the cancer and cardiovascular. I have personally a problem with that statement. I mean, I don't agree with the statement. Heightened risk of cardiovascular disease, really? Is that true? I mean, I don't know. Probably not. And the various types of cancer associated with firefighting. I mean, they are, if you do a PubMed search on cancer and firefighter, the last time I did it was a couple of days ago, I think there are 258 articles. There are about 20 cohort studies. The results are all over the place. Now, at least it's associated, not caused. That's a good one. But there is clearly no consistency of the evidence. Now, occupational stress and hormone imbalance, they actually define it and they say that they believe that firefighters have make less testosterone than the general population. Again, true or not, there is no reference. How you do that, I don't know. So that's where I get to ask you a question. For the docs, or healthcare, medical providers in the room who deal with firefighters and fire departments, so how many comply with all of that? One C, at least one C here. Yeah, oh, no, is that a one or no? Or zero? Zero, okay, zero. And we did the same survey within the NFPA committee members who are physicians, and the answer is zero. I'll let you decide what to do with that. And finally, they get to do an annual ARB capacity measurement. Typically, the docs don't do that, but we get to see the results. If the measurement is under 12 minutes, you are supposed to act on it. Now, there is a threshold for eight, another one for 10. Eight, basically, they're restricted, but you need to get that result, even if you don't get to do it. And we have 16 minutes left for questions. Okay. If you want to ask questions, please come to the microphone, and we'd like to know whether Dr. Arnold is on the call. On the call. If not, then I'll make Fabrice answer all the COPD questions. Oh, no, there it is. Good morning, Chris. Wait, we're not hearing you yet. Okay. All right. I have two questions. So one is for FHIR doing the EKG annually after the age of 40. What exactly are we looking for? You know, an EKG is a snapshot in time. What are we actually getting from that? That's my first question. Yeah. So this is what an FPA requires, and we had heated discussions on that, because, exactly, I mean, that was the argument, and the counter-argument from the union is it's cheap. Maybe you'll find something. Now, you could be looking, so first for an applicant, you're looking for something very different, which is hypertrophic cardiomyopathy and arrhythmogenic cardiomyopathy. I think that's the one that are killing young firefighters or young athletes. I personally be looking for LVH and signs of coronary artery disease, or past event, past MI. That's the two things I'd be looking for, but hopefully you get the same EKG and the changes, but you're right. And then how do you feel about doing stress testing versus CT calcium scoring for those in moderate to high risk? So what, first, let me tell you what NFPA says. What NFPA says is you, it's here, let's see. I don't have the projection, but you calculate the score every year. You calculate the ASCVD score. You have the choice between a two-year score and a 10-year score, and if it reaches a certain level, you need to do something about it. The something is a stress test. They have the calcium scoring in the annex material. I think you're getting different type of information. I can tell you within our group, whether it's the LEO or the NFPA, we have an advocate for the calcium scoring. These are people doing exertional work. Advocate for risk stratification. I want to know how they do at a level of 12 METS, and even if they can do the 12 METS, the calcium scoring is not going to answer that question. I think the calcium scoring could be a nice supplement. It does not replace a stress test. Okay, thank you. Stress test with imaging, for everybody, yes. Stress test with imaging. At least that's the one we recommend here. Dr. Mignone. Two questions, thank you, sir. Two questions, one for Dr. Arnold, one for Dr. Chernecki. Dr. Arnold, is there any value to more objective measurements of pulmonary functions such as pulmonary stress? Any of the tools that are out there? Can you hear me? Yes. Good. Since I was told there's a delay and I've been fiddling with trying to get the Vimeo volume down so that there's no echo, I hope there's none for all of the online viewers. Yes, there certainly is a value to doing formalized cardiopulmonary measurements or formalized cardiopulmonary, you wanna call it stress testing, with someone hooked up to masks and measuring diffusion, CO2 diffusion, et cetera. However, it's so cumbersome that it's beyond the scope of most screening or certainly most occupational examinations. This would be falling more in the category, I think, where you as the occupational evaluator have a question of what's really going on here and you would send them back to their primary or treating physician and say, look, we need to sort this out and we need to know more precisely what the status is of this particular individual in terms of their respiratory disease versus, in this case, it's usually versus trying to sort out what's in a fitness prob. Does that answer your question? Yeah, I mean, obviously, just the performance of the job, the job task performance, I mean, that makes sense. They're actually able to do it regardless of what their pulmonary test would show. Right, and the job task simulation testing ideally would be much like an obstacle course of some sort like a lot of fire departments have. These are much less common certainly in EMS and corrections officer training or screening. They are present in some states in law enforcement screening where there's some sort of a physical abilities test. I'm based in Massachusetts and the state has a test that all police applicants must go through. This was designed by a psychology, actual consulting company, through interviews with, I can't remember, several hundred police, incoming police officers and then creating basically a test that's done in the gymnasium where people run around a couple laps of the basketball course have to go through a fake window that's up a couple of steps, pull a dummy down from a weighted charge and pull a dummy across the floor and also do a trigger pull, climb a small wall. And it's all timed. So there's an aerobic capacity aspect of it as well as pure strength aspect. Now this is, again, this is something set up by the state. All of this set up was paid for by the state and it's difficult to imagine that many individual departments would do this. So in reality, surrogate testing is likely to be what's going to be done by a lot of evaluators or a lot of departments who are needing to be sure that persons can accomplish the test. And probably what really happens is that people are let in and then it's can they make it through the academy or not, which is not really what we're trying to promulgate. Great, thank you. And then for Dr. Czarnecki, I really liked the idea of the scaled down exam. I mean, we all know everything you need to know comes from the medical history. I was curious though, I didn't see you include some level of an orthopedic hands-on physical assessment or assessment of BMI. Well, let's go to the BMI. Let's keep the ortho. I think the ortho, I see that as a fitness for duty issue. So unless management tells you there's a problem, I don't think I want to go there. But BMI, so what is the BMI study to, what do you do? At NFPA, I used to have a BMI standard. They got rid of it because clearly it's illegal, it's irrational. But probably you'll find out that you're sent. Here, here's Joe. Joe is now 395 pounds. And we want you to find him unfit. Why? Well, Joe, he can't get up the ladder anymore and he can't fit through the window and he's slow. And what are those things? Is any of those a medical condition? Those are all performance issues. And so here's, this comes under N, M, J. This is not my job. You're the chief, you get paid the big bucks. If he's not performing, write him up. If he keeps not reporting, write him up again. Write him up again and fire him. And I have had them. And really, when we worked with Jolinda Johnson, who was the EOC lawyer for FEMA, and we did a whole talk on this, basically said, if they send you someone for a fitness for duty evaluation and they don't tell you what the job problem is, don't do it. And this is one of those times. You're not telling me, you're telling me it's a job performance issue. Now, if you're saying, Joe's having trouble. He gets really short of breath. We wanna know if there's some other medical condition. Does he have asthma? Does he have heart? Something like that, okay. But he doesn't fit through the window and he can't get up the ladder. Or we wanna know, has he got bad hips? Again, if there's a medical question, possible medical question involved, yes. But you're not gonna disqualify him because he's 395 pounds. And then the follow up would be, what about using the BMI along with other biometrics to screen for sleep apnea? Who? So, yeah, well, that's, I mean, you know how sensitive an issue that is. What do you do with the results? And this is not a wellness exam. That's why I'm asking the question, yeah. If you wanna do wellness and even an Epworth for a wellness exam, we don't have any problem. This is a fitness for duty. If your job's on the line, your blood pressure is high, you're restricted. If your blood pressure stays high, you may lose your job. So I say so far, it's a group consensus. The answer's probably no. But conversely, if the chief says, hey, Joe's falling asleep at the wheel. Different story. Okay. Different story, yes. Would you include some of the Berlin or stop gang components into the medical history? It's there. It is there. There, there. I think the Epworth is there. Okay, great. Thanks. Thanks, Joe. This is a question on whose job is it? So a person comes in, LAO or firefighter. We use the AECOM committee. Thank you very much. Medical history. They fill it out and then we have access through an electronic medical record that there's a lot more going on than the person has admitted. Ooh, big mistake right there. Why do you have access to the medical record? We have access to the medical record because before we agree to actually see the applicant or periodic exam, they have signed a medical release giving us permission to have access to their medical record. Okay, there's a good reason. And we refuse to see them and the employers know that we will refuse to see them if they do not sign that form. They do not get even vitals or PNACA. So we find out that they, we have a mismatch of something that could significantly affect their ability to do their job that is a medical issue. The fact that they have a mismatch, is that a legal issue? Do we ask that to be reviewed by say, the psychology reviewer? Is that a medical thing? Do we, I mean, we give them permission to correct it. Is that an applicant? I've seen it in applicants and I've seen it in periodic. Let's say it's a periodic. That's called misconduct in human resources. Personally, what I would do, no, you probably should have a plan before that happens. If you don't have the plan, that's okay. Personally, I would stop the exam. You know, the exam's basically not valid. And I don't use the word mismatched. You know, it's called lying. And I would report it. And look, this is a police officer with a car and a gun given by the government. Now, reading the newspaper, there's a case of an FBI agent who was accused of lying. Now, whether he lied or not, that's another question. The guy got locked up. He got fired and he got locked up. I'm not talking about, hey, maybe you get suspended. Maybe you lose your job. No, he got locked up. Again, he's claiming that he didn't lie. I'm not going to go there. That's beyond. But I think I would report it to the agency and say, you deal with that person. Now, if they put in writing that they want you to continue with the exam and give a medical opinion, you can certainly do it. If you suspect, I would only use the psychologist. If you suspect that there is a mental health condition, but lying is not a mental health condition. And I mean, my deal with my management with that type of thing, if somebody lies and they don't get fired, I don't understand why we do periodic exams then. I mean, if there are no consequences, why are we doing that? And it's not my job. For candidates, it's the same thing. I mean, most departments, you lie in your application, you're done, you're fired, you're done. So report that to the employer that the exam was stopped because we found that they were lying. Yeah, find a different word, but yeah. That's the mismatch. Thank you very much. Inconsistent, I think. I use the word inconsistency. Inconsistency is always a good one. But I don't think it's our job. Then Chris, you had that, what was it, motorcycle officer? The story that fell asleep, you always kept falling asleep and, oh good, we can't hear him. That's our favorite Chris when we can't hear him. Did we cut Chris out for some reason? No. No, I'm back, I think we're back now. Yeah, you're good. I muted my mic while the other questions were going on. So yeah, I can't tell you all the details now. It's a number of years ago. But essentially, it was an officer who had, and I can't remember, it wasn't sleep apnea. It was some other issue he had, but he was. Who's diabetic, right? You would get hypoglycemic. Maybe it was that, maybe it was that. He was getting out of it somehow. And he was part of the motorcycle team, but there were several stories, at least two occasions, where heading to something, leading a convoy of some sort, he was in formation and he started to do something weird and his buddies recognized it. So they just sort of nudged their Harleys up next to his Harley close enough that they were kind of supporting him as they were going, oh, it's this guy who's having seizures. That's what it was, that was his problem. He had had a severe problem with seizures that had gotten him into the situation of getting temporal lobe seizures. He got in a situation of getting close to being dropped from the apartment. He was a longtime guy, big motorcycle guy, and he had decided he wanted to go for the gold and had surgical removal of the seizure area. However, what do you know? His brain was still irritated, so he kept having seizures after he was back and he had hidden this from both his doctors and from us, obviously. So that was it, he was having absence episodes while he was driving his motorcycle and these guys would nudge up their other two motorcycles next to him and wait until he sort of slowed down enough, because he was out of it enough that he wasn't pulling the throttle. And then they would just support him and get him off the bike and he'd come around and say, hey, hi guys, how am I doing? The reason I asked Chris to bring this up is we talk about misinformation. It doesn't always come from the person. It can come, especially in police, you know, the veil of secrecy, the blue, was it the blue, whatever, is that, you know, they will cover for each other and lie for each other. So that's another source sometimes of misinformation. Yeah, absolutely. So are we out of time, guys? Yes. We're done. Oh, we're over time, shame on us. Thank you all. Thanks for coming. Congratulations. Congratulations. Thank you. See you in Philly. All right. Will you be there, Chris? Commit now. Oh, I don't know what's to tempt me elsewhere. Okay, be well. Order to family obligation shows. Yeah, Steve Fisher has swapped emails.

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online course

transgender and gender diverse individuals

fitness for duty evaluations

physical effects of transitioning

mental health issues

psychological issues

appendices in a document

glossary

medical care

periodic exams