So, welcome to the NIOSH Firefighter Fatality Investigation and Prevention Program. Kind of an introduction, might be able to tell you a little bit about some lessons learned of all those things involved with our program. I'm glad to be here and glad that you all came by to hear about our program. Again, I'm Rob Saunders, I'm listed as the fire investigator, it's really not the common language for my neck of the woods. I don't do fire investigation, cause and determination after a fire, but it's really just part of our program. I'm a retired firefighter, fire chief from Pike Township, Indianapolis, after 31 years and I've been with NIOSH for a little over three. I have my colleague with me, Dr. Judy Eisenberg, she'll introduce herself when she takes over the program here in about 15 to 20 minutes, so I'll run through this pretty quick. So again, we're the NIOSH Firefighter Fatality Investigation Program and we're the medical team. So to start this, the overview is we'll talk a little bit about the fire service, give you a little bit of an overview, you probably already have a pretty good idea of what a firefighter is, but maybe throw out a few statistics, a few things about the fire service that we pay attention to, kind of listen to in our program. We'll talk about our program, the structure, and then the investigation process, and then Dr. Eisenberg will take over and kind of bring it together for you, the occupational health physician. So fire service 101, and what do we want to know a little bit about the firefighter? We have a definition up there, again you probably don't really need that, you know what a firefighter is. There's some median pay there from 2021, kind of that $50,000 range. Number of jobs, a little over $300,000 and that probably comes from, you'll see kind of that same number with the International Association of Firefighters, that's how many they represent, projected numbers, projected to increase as attention is brought to incidents, especially large scale incidents like we've seen across the country, East Palestine and the training that goes with all that. Prerequisite, as of right now it still is only high school diplomas necessary, they do give points often in some jurisdictions for higher education. And then training, usually received through a fire academy, which is one of the focuses and we will hear a little bit about that as we go through this, and they do obtain some level of emergency medical services. Where I come from everybody has to be at least an EMT. So the environment you'll find us in, structural, wild land, and urban interface, which is where those two kind of meet, funding, there's paid, volunteer, and then there's mixed, often called paid part time, and we, our program will look at all of those across the spectrum. Standards that affect our profession are going to be the NFPA, National Fire Protection Association, and OSHA has a part to play in there, mostly with respirators, the respirator standard. NFPA, everybody familiar with NFPA, has everybody heard of NFPA, yes, and familiar with that? That's really one of the cornerstones, and we'll talk a little bit about that in relation to the occupational health physician. Folks that represent firefighters, probably the two major ones are going to be the IFF, the International Association of Firefighters, representing that over 300,000 across the US and Canada in their representation, and the NVFC, the National Volunteer Firefighters Council, who represents the majority of volunteers. I would say that probably, that number does not represent the number of volunteers in America, but the number that belong to the organization. Other related organizations that represent firefighters and have an interest in our program, again the US Fire Administration, and we have an interest in theirs, that's where we, the US Fire Administration publishes the account of firefighter deaths in the US, and that's mainly how we get notified for our investigations, is we go by the US, the Fire Administration listing of firefighter fatalities, so those get announced, we get a notification of it, and then I talk to those different fire departments. It is publicly available on the web, on their website, and you can see the number. There's probably anywhere from, the average shifts a little bit, but kind of depends on the year, but anywhere from 60 to 100 considered to be line of duty deaths for firefighters in a year, and it's almost split right down the middle invariably, medical versus traumatic. The National Fallen Firefighters Foundation, also a group interested in preventing fatalities and injuries in the fire service, that you have a heavy concentration on support of families after a line of duty death, and then the Congressional Fire Service Institute, which spends their time educating members of Congress on the needs of the fire service. So what is a line of duty death? And that, again, plays a big part into our program, because that's where we concentrate, is a line of duty death. So we have to find a definition, we're still the federal government, that kind of encompasses where we fall in, in our program. So we do follow pretty much the PSOB, the Public Safety Officers Benefit, which is a one-time benefit program administered by the federal government, and specifically the Department of Justice handles that when a firefighter dies in the line of duty. So standards, and this is, again, where we begin to start to tie it to the occupational health physician. So we talked about NFPA earlier, that's where we lean in on a lot of our recommendations is going to be NFPA, and we do kind of marry it up with OSHA, OSHA versus NFPA. OSHA standards are mandatory and enforceable, and their play on the fire service is very much cornered on the respiratory protection part, the SCBA we wear, the N95s, or even the half-face respirators, that's where OSHA plays in on those FIT standards. And NFPA, those are consensus standards, so they really are the only ones that we subscribe to that are written down in the fire service, and they are accessible online and are free to join, to be able to view those in an online fashion. So as we narrow down a little closer here, our program on the medical side, and it's probably a good point to show, tell you a little bit about it, so we are the medical side. The traumatic, the firefighter fatality program is actually split up into two teams, the medical and the traumatic. We work out of Cincinnati, Ohio, it's just Dr. Eisenberg and I, and we investigate medical line of duty deaths. The traumatic side works out of Morgantown, West Virginia, there's about six to seven of them, and they do the traumatic fatalities. So we look at ones related to heart attacks on the scene, part of our definition is deaths that would occur within 24 hours of the incident or leaving shift, which is part of the HEROES Act passed by Congress to extend line of duty death past the shift, and that's kind of specific to medical. So we concentrate on the 1500 series, we'll call it. There is an effort in NFPA, I say an effort, but they're in the process, it'll become one standard instead of the four that you see, and I think there will be a fifth, it'll all become NFPA 1500, but we concentrate on 1581, 1582, 1583, and 1584, and then really specifically on 1582. Is anyone familiar with NFPA 1582? A few people? No familiarity at all? Anybody? None? Some? Maybe? So 1582 is probably what I would call one of the reasons that we're here, to kind of bring some light to our program, is because in my opinion, in our opinion, probably the occupational health physician is probably the closest one that's mentioned in NFPA 1582. I would almost say you are mentioned, the occupational health physician. They call it the fire department physician, is mentioned many times in 1582, they're called the fire department physician, and the things that they should be familiar with when examining or being a part of firefighter health and firefighter wellness programs. Everything from new hires, hiring new firefighters to return to work after an injury, illness, or even rehabilitation. There's a lot that goes into that, and definitely want to emphasize this point. So when we have a recommendation, we investigate, we come up with recommendations, and you'll probably see this again, but it's worth emphasizing. There's really kind of three regular recommendations we have in our reports, and one of them is that the firefighter sees a physician familiar with firefighting tasks, and that is you, the occupational health physician, 99% of the time. So the structure and investigation process of our program. So just a little bit of history. We were created in 1998, I believe that was during the Clinton administration. It was kind of heavy involvement between them and the IFF that our program came to fruition. Anybody familiar with NIOSH's HHE program, Health Hazard Evaluation? So Health Hazard Evaluation program, so whether you're in Cincinnati, Ohio, or Morgantown, West Virginia, everyone else around us does HHEs. In fact, Dr. Eisenberg came from the HHE program. So there's a little bit of a difference, even though we are kind of all in the same area or same divisions, if you will. HHE program has right of access, and this is an important part for us, is the firefighter fatality program does not have right of access. So we, when an HHE program, within that program, if any other organization or industry wants an HHE done, evaluate for hazards in their processes, once that's termed to be a valid request, then the HHE program goes in, and they have a right to go in, and you can't tell them no. In our program, it is completely voluntary. And even a lot of fire service people, and I really was not totally clear on that in my time in the fire service, that you do, an organization does not have to let us in. We do not have, we have no right of entry. Now oftentimes, the fire departments want us in, and that's because of the nature of the event, the firefighters died, the worst thing has happened, and often they are looking for a third party, an impartial party, to come in and take a look at the event and produce those results. So that's, it's voluntary, the program's divided, we talked about that. And all the reports are posted online, so that's another thing, that is the completion of the process, our reports are posted online for everyone to see, and that is the final resting place. An investigation, depending on the program, our program takes about a year to put one out. The trauma side can take up to two years, and sometimes even longer, depending on the size of the incident, and sometimes that can even be affected by having multiple fatalities. We do use an algorithm to kind of determine what we'll investigate, because even though again we're voluntary, as I said, fire departments want us to come in and take a look at the, at their event, so we cannot investigate all deaths. On average, and COVID kind of put us in an interesting place, because also if you didn't know, and you probably do know this, NIOSH is a division of the CDC, so when COVID hit, a lot of our folks in NIOSH were taken to the COVID response, so those three years are probably not good years to kind of count how many investigations we do, but on average, post that and what we're spinning back up to, we'll investigate about a third of firefighter deaths, about 33% of firefighter deaths that occur in a year, between both programs. But we have a heavy concentration, so this algorithm was just redone in the last six months or so, through a fire service meeting, community meeting we had, that we look at, they give us feedback on both of our programs. When a light and duty death comes in, we triage it to the medical or the trauma team, and as you can see by both parts of the diagram, there's a heavy concentration on training. There's been a number of deaths in the last couple years, and this year has already started off to be, unfortunately, headed in the same direction that there's still firefighters dying in training, not even on a working incident, whether it be heart attack, heat injury, or some sort of combination of the two, and then we kind of go down the list, and that gives us a yes to investigate, but that's also based on our resources and availability. So I don't know who that is there, but the process, a couple slides on this, we'll review those notices, I'll contact them, so I am the one on the medical side, I send a communication to every fatality, I don't always hear back, and I don't need to hear back again because we're a voluntary program, but I usually communicate with every department, have an introductory meeting where we kind of spend about 20 to 30 minutes going over the incident, what occurred, and then we kind of decide between the two of us, me and the organization leader, again, 99% of the time, that's the fire chief, if we're going to consider this for an investigation. We take a look at that prioritization criteria, and then I also lean on that fire chief to be the specific one who gives me the green light that he wants us to come in. I give him, I tell that individual, though, that we want, how he comes to that decision is up to him, it's talk to the family, staff, elected officials, but it is that decision of the fire chief to have us come in or not. We'll interview, when we go on site, we'll interview as many people that want to participate that are specific to the incident, leadership, leadership is often involved in giving us written policy, their procedures, their wellness culture, where physicals fit in, we'll talk to people on shift with the individual, people that were part of the incident as applicable. Family and spouse, we want family and spouses and anyone else to be involved, we want to have their input. They can provide valuable information about history, medical history, but it also can be a big part of closure for those parts of the family as well, but if they don't want to participate, that's also okay with us too, we can move on from there. We'll review those documents, again, a lot of them policy, we'll also get medical records, transport records, patient care reports, and if applicable, we'll check out the scene of the incident. All of that culminates in a first draft report, we do send that for a courtesy review to the family and the department. That is really not to kind of find their take on our recommendations, our contributing factors and recommendations, but it's also meant to just make sure we've represented the fire department and what they've told us correctly, and then it's cleared and put on the website. And that's what we do, we look for those decision branch points and knowledge gaps and hopefully to prevent deaths and injury in the future. So with that, I'm going to turn it over to Dr. Eisenberg. Thank you, sir. Good morning, everyone. Again, thank you for attending this session, first thing in the morning in the conference week, we really appreciate it. To introduce myself a little bit, as Rob said, I've been with NIOSH quite a long time, 19th and you can't hear me. Can you hear me better now? All right, cool, thank you. So as Rob said, I've been with NIOSH quite some time, 19 years, 16 of which have been in the Health Hazard Evaluation Program and some of you have may seen me here in previous years when I presented on my prior HHEs on heat-related rhabdomyolysis in structural firefighter cadets and Death Valley National Park employees. So this may be a little familiar if you were here in previous years. I am board certified in emergency medicine, and I am also the director of our occupational medicine rotation program, which I am very happy to say, after the COVID hiatus, we're now getting it restarted again. In your packets, you should have seen a postcard that describes that reopening and the link to our website. And I have additional postcards in my cards on the front table if you did not get one of those. So we are looking forward to getting that program back up and running again. And hopefully, we'll see some of your residents. So let's talk about physician roles in the fire service. So as Rob said, the fire department physician is a position specifically delineated by each department. And it may be a contract out to a health group. They may have their in-house department. Or especially in cases of volunteer departments that don't have resources, they may rely on the firefighter's individual private family doctor to do their medical assessments. But those are separate physicians from the designated fire department physician. And whether they're the designated fire department physician or a family doc doing a medical screening, physicians come into contact with firefighters in several points of their career lifetime. First, when they're applying to cadet school, if that's part of their career process that they have to go through to see if they're fit to start training as a firefighter. For incumbent firefighters, and what incumbent firefighters are are those who are ready certified, who are out in practice. So they're not new guys. They're the returning guys. So every year, it's recommended they get an annual medical assessment. And if they're applying to a new fire department, even if they are an incumbent, the new department will want to have, again, a medical evaluation before they join the other department. And lastly, following either an illness or an injury, they should have a medical assessment to make sure that they are clear to go back to work, basically a fit-for-duty evaluation. And regardless of which of these are done, the physician signing off on that medical clearance form has to basically certify that not only are they medically clear to do the job, but the physicians themselves is, quote unquote, familiar with the essential firefighting tasks that they are now being cleared to perform. And just to give you an idea of what the designated fire department physician has to do, anybody, pretty much any licensed osteo or allopath can be a fire department physician. And they're basically responsible of implementing all the criteria that's described in the NFPA 5082 standards. And it comes into two big groups. One is to make sure that the firefighter is fit for duty and to understand the categories, what's called A and B of medical conditions. Category A conditions are immediate disqualifiers from fitness for duty. So that's basically do not pass go. Category B conditions are ones that could impact service. And they have to be evaluated on a case by case basis. And the way they're evaluated is that are they able to do the essential jobs of firefighting, which the NFPA standard also lists out in excruciating detail. So it's very specific. The other component is here in yellow is not only does the fire department physician have to make sure all those assessments are done, but that they have to close the loop to make sure that information gets back to the department to understand, well, not only has this evaluation occurred, but what was the determination? Are they fit to come back? So it's making sure that the loop is closed in the medical assessments, among several other things. And what you can see here is the overall responsibilities of a designated fire department physician. So it's not just the individual medical assessments. It's basically overseeing the program itself from preventive measures to training and pretty much everything else. So some confidentiality issues. The standard recognizes that the department really only needs to know the yes, no determination of fitness for duty. However, many of the fitness for duty forms come with a sign-off line that the person being evaluated releases their medical information to the department. A failure to do so may result in their return to work being delayed or denied. So in essence, that's not something to be surprised if you see that on the form. So they really get all the information from the firefighters. And this is what I was telling you before about certifying your familiarity with the firefighting job when you do an assessment of a firefighter. And this is an example of one return to work form. And you can see that second line, basically the signing physician certifies that they are familiar enough with the job to do an accurate assessment. So the next question is, well, who determines familiarity? If you ask any first grader, they can tell you what a firefighter does. But does that mean they can tell if someone can go back to work as one? So to our knowledge, unfortunately, there is no current certification process to say, yep, I've taken this test. I've proven that I know what the firefighters do and how complicated and intense it is. There's nothing of that. But to our knowledge, there not have been any legal cases that have involved physician familiarity with the firefighting task and something adverse happening afterwards. But it's something to think of if someone comes to you as a return to work or an initial fitness for duty evaluation, and you've never, ever seen a firefighter before as one of your patients, it would probably be a good idea just to peruse the standard to make sure that they truly are able to do all the essential tasks, which certainly before I started doing my investigations, I really did not have a accurate assessment of how intense some of these tasks they have to do are. So if you're not familiar, use the standard to brush up on that familiarity before you certify them as good to go. So I want to talk to you a little bit about our investigative program. As Rob told you, we've been in existence since 1998. And there have been two series of program assessments so far for our program's history. The first one happened from 1998 to 2005, looking at 863 total line of duty deaths. We excluded the ones that occurred on the 9-11 disaster. And we investigated 335 fatal incidents involving 372 deaths. So this, again, highlights that sometimes the incidents that we involve do include multiple fatality events. So unfortunately, we have had experience with those type of things. Of the events that were investigated, a little half were about medical fatalities. And you can see the table one there, how it breaks down. And not surprisingly for all departments, cardiac causes come first. And just to give you a balanced view of the program, here's how the breakdown was for our traumatic side of the program and the types of deaths that they investigated. So it's not terribly surprising that throughout our program's history, the majority of the deaths that we've seen on the medical side are cardiovascular. The U.S. Fire Administration estimates about 45% of all firefighter line of duty deaths are this way. And as Rob stated earlier, the way they get these information, fire departments throughout the U.S., both structural and wild land, they voluntarily report fatalities to the USFA, who then posts it on their website and sends out their notification email. So they're a really good source of these types of statistics. So firefighters are at increased risk for cardiac events because they get the increased heart rate from the exertion of fire suppression and rescue operations. So just if you have never had a chance to put on some turn out gear, the turn out, the big bunker jacket, the pants, and the SCBA tank, that'll put another 40 to 60 pounds on you before you even do anything. And then you're asked to, you know, climb ladders, break through walls with ventilation hooks that themselves can sometimes weigh 40 to 80 pounds, carry chainsaws, you know. It's a very, very physically intense job. So it's not surprisingly that you're going to get your heart rate up doing it. Also, this whole idea of sudden awakening from a heart attack and also this whole idea of sudden awakening from sleep when you get a call in the middle of the night. Before I started, during my first two years of medical school, I was in EMT with a rescue squad, and we had mandatory overnights. And in our bunk room, there were speakers all over our ceiling and flood lamps. So whenever our tones came across that would alert us to a call, the system would automatically ramp up the volume and the floodlights would go on. So you were basically startled awake. And you could always tell who the new volunteers were who just had this sort of startled doe appearance when they were scrambling out to the rig. So it's not surprising that having that sort of alert go off would cause your heart rate and blood pressure to go through the roof. And actually, some departments and their companies that are working on systems that you see here to the right to have sort of a ramped-up lighting system, a ramped-up volume of the tone so it isn't as jarring and doesn't cause that sudden adrenaline surge. And chronic sleep deprivation also puts these firefighters at risk for cardiac events. So sleep apnea aside, just the whole idea of whether their sleep is getting interrupted or they're basically sleep deprived if they're a very busy department and basically running their entire 24-hour shift sometimes. So that all adds up into preexisting risk factors for cardiac events. So the second round of review of our program was over 2006 to 2014. And we looked at 41% of the fatalities reported through the NFPA instead of the USFA during that study period. And it breaks out the same. You see about equal split between medical and trauma. And here are the actual causes of death listed. And for the medical side, coronary heart disease and other cardiac events come first. And we looked at the recommendations given through the two assessment periods. And they were very consistent on the medical side with going through and looking at how the department does their screening, fitness and wellness, and clearance for duty. And it's not that we're being redundant, but I'm sure as you know how a policy is written may sometimes be very different to how it's actually put into practice or interpreted. So oftentimes when we do these investigations, what really helps the department is for us to sort of have a fresh set of eyes to pick through their policies and procedures to see if their policy is written so that it's consistent with NFPA standard, but also how is it being implemented in practice. And we can sometimes find out issues. And you'll see that in the example I'll give you in a minute. So I'm going to go through an example of one fatality case we had from 2019. And this unfortunately was a heat stroke death during cadet training. And as per our decision algorithm, this came up as a priority both as a death during training and a death due to hyperthermia. So it was certainly on our radar to go investigate. This was a 35-year-old cadet who died from heat stroke participating in what's called a consumption course during second week of training. And what a consumption course is, it's a way to teach someone who has never used an SCBA in their life to get used to the idea of air management. So it can either be done as you see on the photo here as a treadmill walk in full gear and SCBAs and they run down their tanks, or it can be done as sort of an obstacle course with them going through their tanks during an obstacle course and they have to see how much of the course they can get through before they use up their supplied air. So this cadet class was a little bit unique in that it was a bridge course in that all the cadets in the class were already certified as volunteer firefighters. And they were taking this course as an extra 200 hours of training to meet their state certification requirement to become career firefighters. So unlike most cadets where they're coming in from no experience, all the cadets here did have some experience using their SCBAs. Their consumption course had 10 tasks that they had to do throughout the course and the cadets had to finish two loops through their course with given two bottles of air. And if they use up their air, supplied air before they finish the course, what happens is they just take the regulator out and finish the course on room air. And the whole idea is you do this course repeatedly so you can start to monitor how you're breathing and how your exertion impacts your air usage. So they run them through this course multiple times during training to get them better at managing their air supply and effort. So the first day of week one is basically administrative tasks. They don't really do much exertion. It's the second day of the first week of training that they do their first attempt at the consumption course. And this was in June at 2 in the afternoon. The ambient temperature was 79. Heat index was 80. And all 15 cadets completed the course. Okay. The candidate who died and we refer to them as candidates so we don't have to keep saying cadet who died. So he's a cadet but that's the one we're talking about in this case. So he did say he had some shortness of breath and dizziness while in the rehab area on the completion course. And a rehab area is an area that's next to training courses and fire locations and it's an area where firefighters can be medically evaluated and assessed. So if they're doing a long response on a structure fire and they're changing out teams so as each firefighter comes out they go to the rehab area where they're medically checked and rehydrated and just taken care of before they go back in. Or if they come with a medical emergency, the rehab area is there and it's staffed by healthcare professionals either at an EMT or paramedic level and there's usually a transport vehicle there like an ambulance in case they do need transport. So at that time the on-site paramedic diagnosed the candidate with heat exhaustion and dehydration. He got some IV fluids and he was advised to seek a medical evaluation. He said, oh, he was okay and he felt better after the IV fluids and went back to training. And day three of week one, they did the second round of the consumption course and everybody completed it. He didn't need any treatment at that time. Day four and five of week one consisted of other types of strenuous exercises but not consumption course. And on Friday, day five of week one, the candidate said he really wasn't feeling well when they were in the carpool ride going home. So after he got home, he then went to his local urgent care center and told them he was having chest condition, progressive cough and fatigue for four days and was found to have mild bronchi of both upper lung fields. He was diagnosed with acute bronchitis, given antibiotics and steroids and prescribed antibiotics and a cough suppressant to go home. And on Sunday, he talked to his chief and let him know he went to go see what he was diagnosed with but, you know, he's feeling completely okay. He's on these meds and the chief was like, yeah, it's okay. Come on back for training. So week two, day one, so the next day on Monday was the third round of the consumption course. They started at eight in the morning and, again, the temperature wasn't too bad outside, 81 degrees Fahrenheit with a heat index of 84. And the candidate was on his last test on the second loop where he just went to his knees and said he just could not move. He could not get up. He had to be assisted, basically walked over to the rehab area and was really out of it. And by the time they tried to get a blood pressure on him, he'd gone into cardiac arrest. They tried to resuscitate him, got a quick transport and totally unsuccessful. He was pronounced dead at 10 o'clock. So really quick progression of this. So his autopsy results did show he had an elevated BMI. And this is common in firefighters, not because they're all obese, but because many of them are fit. So rather than going by the general BMI, they tend to do also taping to take into account that it's more muscle than adipose that's there. So that's an issue that is very sensitive in the fire service that, you know, just because they come in at high BMIs, they're not all out of shape. However, the examiner did notice the rectal temp on arrival to the ED. So a half hour after he went down, they had a rectal temp of nearly 104. So the autopsy found no urine and bladder consistent with dehydration. They did find cardiomegaly with biventricular dilatation, but they couldn't say for sure whether that was a contributing factor to the death. He did have normal coronary arteries and no sign of a recent or prior MI with any sort of focal cardiac lesions indicating as such. Tox screen negative, carboxyhemoglobin negative, and unfortunately there was no CK done by the emergency department for a rhabdomyolysis evaluation. And not surprisingly how quickly he came in and just they started the resuscitation immediately. The cause of death was listed as probable heat stroke. So what did we find? He had no prior history before his cadet training of heat stroke. His home volunteer fire department, not surprisingly, their medical evaluation was not as comprehensive in NFP standards and they did not have a wellness and fitness program. And one of the things that you'll see in NFP standards, as Rob said, they are consensus standards. They are the ideal of what we would like to see in all fire departments. But it's also recognized that volunteer departments that don't have often the funding and the resources to do the shiny Cadillac version of medical exam and screening that a well-funded municipal department does. So we acknowledge that in our evaluations but still point out where they could improve. Now the cadet training pre-placement medical evaluation was done by a PA but never signed off by a physician, which is again specifically stated in the standard 1582 that the medical evaluation has to be done by a licensed physician. So we found that that was a deficiency in this case. And his medical evaluation occurred six months before he actually started the cadet course and there was no re-screening requirement. And we found this in other investigations and even one of my prior HATs where some departments are really big so they train a lot of cadets but once they get them through training, for some departments it can be up to two years until they hit that training course. So in those cases we actually recommend that the department institute a re-evaluation standard if there's going to be a considerable delay between the initial medical assessment done as part of their cadet application and when they hit the door of the training class to make sure nothing significant has come up in their medical history in the interim process. And as you heard, the cadet did not have a mandated medical evaluation before returning to training after he got treated at the urgent care for his bronchitis. So there was no one again laying eyes on him to see what was going on and maybe intervene at that point. So some of the things that we recommended, again pre-placement annual and return to work medical evaluations to be consistent with the 1582 standards with the level of provider performing the evaluation, again with the provider familiarity with the firefighter test so that they are capable of signing off that they're fit to return to those exact duties and the specific content of the evaluation. And we asked the training center to look at their policies because whether they did have a policy in place that actually said that this needed to happen before his return to work following treatment or evaluation for an illness, and then we asked them to consider retraining on heat-related illness and rhabdomyolysis. So we know that with the exertion, the heat trapping of the turnout gear and the additional weight of the equipment they wear, that firefighters are at risk for rhabdo from heat exposure as well as the exertion. So that needs to be recognized, but one of the things that we teach about rhabdo and you can see on here is from my prior HHEs, we put out a new NIOSH rhabdo topic page and included handouts for both the firefighters for structural and wild land separate documents for both the firefighters and their health care providers describing these inherent risks. And one of the things that we go to teach about rhabdo is sort of the great mimicker of anything, that one of the hallmarks of rhabdo is fatigue or pain out of what would normally be expected for that particular exertion. So the fact that this guy, he'd worn an SCBA before, he was a volunteer, he'd been through the course two prior times before this, and now suddenly he goes down to his knees and just can't get up. So could there have been rhabdo going on since the consumption course first or second time and it had just progressed so it got severe enough that it brought on these symptoms? And certainly, you know, in cases of severe rhabdo, hyperkalemia can induce fatal arrhythmias. And when you look at the fast progression of him starting the course at 8 a.m. and was down by 9.30, you know, that would certainly be consistent. But unfortunately, we don't have, you know, there's no way to prove it retrospectively. So for follow-up, we did follow-up with the department a year after our final report was issued. And the fire department did take a look at their policy, so maybe it's not written as clear as it could be. So they actually went back and rewrote the policy to be a little bit more clear of what had to happen before candidates come back to training after an illness. And they did add the training materials for rhabdo and heat-related illness to their program. So what are the take-home lessons here? Firefighter tasks are very complex, require high-level exertion, and if you're not familiar with firefighting itself, it's a real eye-opener to read through the standards to see what they have to do and how difficult it truly is. So it's really important for physicians evaluating firefighters in any part of their career is to really have a good idea of what you're sending them back to. And any physicians who have ongoing partnerships with fire departments or training programs as the designated department physician should also check their evaluation policies. Again, what's in place versus what's in practice may be two different things, so make sure they're being consistent and that staff truly understand what the policies are directing them to do. And if they don't have these wellness fitness programs in place, that they really should start one because prevention is a huge part of the health issue with firefighters. And actually the IAFF has a really nice guide for departments on setting up a wellness and fitness program. So that's all we have. Thank you very much, and we'll take any questions. Yes? Hi, I have a question. Last week there was an unfortunate two firefighter deaths in Chicago within 24 hours of each other. No, in separate fires. One was from, I think, cardiovascular, and one was from heat and carbon monoxide. But having worked with firefighters sporadically over the years, I have a question. Is there any effort being emphasized in education, training, monitoring, assessment of lifestyle medicine to change some aspects of the negative part of the culture of firefighters' health care, taking care of their own health, maintaining their health? Yeah, that's part of what you see up here is the wellness and fitness initiatives I'm talking about that not only talks about keeping physically fit, nutrition, as well as mental health issues, stress reduction, and things like that. So it's all encompassing. And being an EMT myself, and I started working with firefighters in the HHE program back in 2010 with wildland firefighters, it is certainly hard to get first responders to take care of themselves as good as they take care of other people. And culture is really, really hard to change. So getting a firefighter to say, you know, maybe this isn't good or I'm not feeling well, it's really hard to change that culture of just suck it up and tough it out. And all we can do is try one-on-one education, one-on-one discussions with the department and the leadership that they trust. So yes, all that is an ongoing challenge for us when we do these investigations. Thank you. And one more quick question. Is there anything being done to address the status of constant and chronic sleep deprivation for most firefighters? Because I think that's a big factor in their overall... Right, and as I said that, we recognize that that's part of their cardiac risk factors is sleep deprivation and sleep interruption. And it's really hard to take that out of the equation, especially when most departments either do 12 or even 24-hour shifts. You're just not going to get sleep unless you're in a very slow department. And unfortunately, it's sort of the nature of the beast. And all we can do is try to work around it and make that awakening as less jarring as possible, like those ramp-up systems for call lighting and things like that. So those efforts are certainly into play and certainly recognized as factors. Thank you. Hello, my name is Dr. Leffer. I'm actually the fire doc for Montgomery County Government with about 1,200 volunteers and 1,200 career. I'm working for Concentra. And first, you had a fantastic presentation. Thank you. On this case here, though, I might suggest that this wasn't what we think. And because given the autopsy, I don't think it's normal for any 35-year-old to have biventricular heart failure. And so, I mean, who knows? But what I'm suggesting is if the pre-placement cadet training had included one of the NFPA stress tests, not as a cardiac sort of factor, but as a cardiac endurance factor, that this might have come up as a can't complete the stress test or something else going on. And he might not even have gotten to this cadet training in the first place. It's just a thought. No, sure. And that's something, you know, it's a chronic problem with volunteer departments. You know, what they would like to do and what they have the resources to do are often very vastly different. And that's something we recognize. And, you know, could it have been identified early and possibly investigated if it was a contributing factor or at least acknowledged and evaluated? We would certainly have preferred that. But, you know, they recognize that, you know, they just didn't have it, have the resources to do it. And if the firefighter cadet's primary care doctor doesn't do an assessment, then, you know, we're kind of stuck. But I agree. You know, it would be awesome if all departments, both volunteer and paid, had the resources to do the thorough workup that NFPA would like to have everybody get. So, absolutely. And just one other thought as part of this in terms of not having the resources. So, we turn it around. When we want to evaluate someone further for cardiovascular after we've done our initial assessment here and they're sending them to a cardiologist, I mean, a perfectly board certified cardiologist who probably doesn't know the specifics for firefighters, along with the request to be evaluated by the cardiologist, we actually send a, this is a copy of the essential job tasks for this particular department. And obviously, I mean, it can vary from department to department. The essential job tasks aren't always the 2022 version of the NFPA. Sometimes it's the 2013, 2018, or sometimes they have their quote unquote own essential job tasks. So, we just make sure that we at least get them the essential job tasks. And if, hopefully, they're using some version of NFPA, if we're sending them to the cardiologist, we'll also say, here's the 2013 cardiac section from NFPA. Because as you know, I mean, these specialists, like you've already said, most of them aren't aware of any of these things and don't have the time to look them up. And so, if we present the four pages to their face along with the question, we find that they're more likely to read those few pages and understand a lot more clearly what they are before saying that they're fit for duty or not. Yeah, you're absolutely right. And that's why we always believe it's so important to involve the physicians in the assessment. And that's why when you see like this rabbit materials we put out, we put them out both for the firefighters and we put out this one specifically for their healthcare providers that they could take to their doctor if needed. Say, like, look, you know, this is what I do. And in case you didn't know, this is how I'm at risk. And if you look on the left-hand column, it actually delineates for the doctor what activities put them at the increased risk. So, absolutely, the more we can get information out to the providers who are doing the assessment, especially ones who really may not be dealing with firefighters better, the better medical assessments and the more accurate return to duty that we'll see. So, thank you. Thank you. Thank you. Good morning. Hi, I'm Ellen Kessler. I've worked with firefighters quite a bit. And one of the questions I have, you had mentioned that he had bronchitis and was on a decongestant. I'm just wondering if he was on an antihistamine decongestant, which can certainly exacerbate rhabdomyolysis. Sure. I mean, most decongestants, the antihistamine component, the Benadryl has been associated with it. Then if you have a decongestant, which is a vasoconstrictor, you're also increasing your risk from that. And you had mentioned that he was on it. Do you know whether he was currently on it during that period of time? No, we do not. Yeah, we were lucky to find out they actually got the urgent care visit. So, it wasn't too terribly detailed, fortunately. But thank you. Hey, good morning. I'm over here, straight ahead, right here. Yeah, I've been like, thank you. So, I actually wanted to follow up on the gentleman's, kind of what he brought about. It just struck a thought in my head. So, I care for some of the firefighters in Tennessee communities. And what is actually unclear to me, and I'm just hoping you can just provide further clarification, is are stress tests a requirement according to the NFPA standards? That's not quite clear to me. We've kind of looked at it from a cardiac risk standpoint. But I have heard in the past, some of these fire chiefs are saying a stress test actually is a requirement prior to any kind of training. Can you just speak to that? So, remember, NFPA standards are consensus standards. We can't enforce any of them. They're what we ideally would like to happen. And after age 40, the NFPA does recommend a stress test, and they perform at least 12 mets on that. But that is certainly under discussion right now. The National Fire Protection Association Technical Committee on Emergency Response and Occupational Health is the one that manages the 1580 series. And myself and Dr. Tom Hales, who you may all know, we sit on that committee as advising. So, that is currently under discussion right now of what those mets should be and if standards should be changed for incumbents versus cadets and things like that. But as the current standard does state that they do recommend for over 40 to have that as part of their assessment. Thank you. Thank you. Hello, I'm Stan Hames. I'm also a member of the NFPA Technical Committee. And as of seven days ago, on April 10th, the Category A and Category B definitions have ceased to exist. There is now one set of criteria for applicants and incumbents in technical. This was processed as a tentative interim agreement, which is actually an amendment to NFPA 1582. It was effective April 10th. It's available on the NFPA website. Unfortunately, the way in which they post it makes it almost unintelligible. But the bottom line is there's only one set of medical criteria for incumbents and applicants. And as far as treadmill testing, that is really only required if a person is coming back from a cardiac intervention. Thank you for your time. So, update from 10 days ago, way after this was submitted. So, thank you so much for that update, sir. Yes? One more thing. About 12 years ago, while working for Concentra, we were taking care of Howard County fire. And long and short is, at that point, it was like the 2005 NFPA, and they had just switched from 9 recommended to 12 recommended. And long and short was, when we published this, we got the whole department from 9 to 12 mandatory, using it as a cardiac, not as a cardiac risk factor, but as a cardiac endurance factor for lots of other things. And along with getting the whole department from 9 to 12, other than 2, we documented an ROI of 5 to 1, with a 60% decrease in, forget about cardiovascular, in work-related injuries across the board for the whole department, going from 9 to 12. So, if anyone's thinking about taking the stress test off, at least strongly recommended by NFPA, I think you might not want to do that. That's just me. Thank you. All right. Thank you. Well, that seems to be all. Thank you, everyone, for coming. And if you have any questions, please don't hesitate to reach out. If you have any residents who might want to visit us, please take a postcard. Thank you, and have a good day.

firefighter fatalities

medical evaluations

cardiovascular events

fitness for duty

investigation process

fire department communication

physician familiarity

firefighter fatality prevention

NFPA standards adherence