It's first thing this morning, hope everybody has had a cup of coffee or something like that. I'm wondering if we can put our slides up. Might that be possible? Anyway, I'm Elisa Kobel. I know I have met some of you before, but welcome to our early morning session on the Provider's Guide to Firefighter Medical Evaluations, which is couched in a much bigger and more interesting topic of a resource hub that we like to call the Science Alliance. So you'll learn a little bit about the content of providing firefighter physicals, but also the resource and information and science hub that we are trying to create that you are all welcome to join. So, I'm sorry, do we have a slide change? It's up here? Okay. It's probably on the podium, but I'm a walker, so I don't spend much time on podiums. Okay. So, let's get started, shall we? So, disclosure, we do not have any financial relationships with any commercial interests related to the content of our presentation today. So, let's talk about session objectives, okay? So first, we're going to talk about health concerns for which firefighters are at unique risk, and other public safety officers as well. You know, we tend to pilot a lot of these things in the fire population, but the truth is it applies to emergency responders across the board, because a lot of the risk factors are the same. We're going to talk about those unique physiologic stressors specific to the firefighter and how they contribute to chronic disease, okay? And we're going to talk about how to make a good screening strategy, okay, for a firefighter patient based on these exposures. Now, you can see over on the left side of the slide here, this is a really, really helpful document. It's super concise. It kind of has all of the important stuff on it. There will be a QR code later that we show you that you can hold your phone up to that can take you to the website that contains all sorts of resources, and not just this one, but other stuff too, okay? So, first we're going to thank our sponsor organization, the First Responder Center for Excellence. I don't know if most of you are probably familiar with it, but it's kind of a subsidiary of the National Fallen Firefighters Foundation. And FRCE does some really cool, what can I call it, interdisciplinary group work, okay? If you go to their website, you'll see that there are several committees. There's a cardiovascular committee, a cancer prevention committee, an annual physicals committee, a general wellness committee, and a behavioral health committee that all do what they can, you know, people all over the country participating to advance this area of science and connect people across the country. So, if you have not checked them out yet, please do. And I just want to give a little shout out to Ed Klima, who is, raise your hand, Ed. Thanks. Yay. Who has taken this organization to the next level. So, thanks very much for that, Ed. So, with the goal of reducing line of duty injuries and deaths, let's talk a little bit about the Science Alliance, like I mentioned. There's this wonderful community of people, and I love seeing every year that it grows a little bit bigger, okay? And again, it's interdisciplinary. There are people from the fire service. There are people from law enforcement. There are people from the scientific community, who you're going to hear from today. There are people from the clinical community, like myself. And, you know, the meetings and the collaborations that come out of this organization that you'll hear more about from my co-speakers, it's just, it's so vibrant and so much fun. So, I would definitely encourage you to check it out, okay? But it's really meant to be a hub, okay? To be a place where the data that is growing yearly and the experiences of those of us in clinical medicine who are treating these populations can all put it in one spot so that we know what's going on. Okay. Ah, there's your first QR. So, if you want to check it out, we'll put this up again at the end of the presentation, but if you want to peek at it, I'll give you a second. And I'm also going to give my co-presenters 100% credit for creating this. They are absolutely the pioneers of this project. So, happy to be a soldier with them. Okay. So, this will come up again. So, if you did not catch it this time, I'll give you another couple seconds. We good? Okay. Let's move on. Okay. So, I'm going to give you a little bit of introduction just in terms of clinical content, okay? So, when we talk about this concept of creating a provider's guide, you know, AHK Health folks like us are a little more dialed in when it comes to what to do with public safety officers, right? These are things that we see pretty frequently in our practice, not only on the, you know, the employer services or physical side, but also on the injury side, right? They get hurt a fair amount, right? So, I just wanted to highlight sort of the rubric that we like to use to make sure we're giving these folks as thorough an evaluation as possible, okay? So, ideally, and this is not true across the board, every year, every firefighter is getting an NFPA 1582 compliant physical, okay? And these are just the highlights. It's actually a much more detailed, you know, description if you get the 1582 document itself. But you're doing a history and physical, you're doing blood work and urinalysis, not to be confused with drug testing because that can be a major trust issue, right? You're doing a hearing test, you're doing a breathing test and a chest x-ray if it's clinically indicated, you're doing a screening EKG and potentially additional cardiac screening if that's indicated. You're going over immunizations and blood-borne pathogen status. Ideally, you're doing a cardiac risk stratification, at least on those 40 and up, and ideally under 40 as well, and cancer screening, which is a huge part of the firefighter community simply because more and more evidence is mounting that, you know, exposures on the job do in fact result in higher risk for cancer. I also included here the framework that I like to use when I'm talking with these folks. There was kind of a hallmark JAMA article in, I believe, 2008, which I think was the shortest hallmark article you'll ever read. It's like a page and a half. But it talks about the lifestyle vital signs, okay? And these are all of the modifiable things that people are in control of, okay, that will contribute to their chronic disease risk. So every time I do a physical, okay, I'm making sure to cover every single one of these concepts, okay? And it's interesting the patterns that emerge when you have this conversation over and over again with hundreds of different people. You start to get a gestalt for, you know, which one of these might be their sort of prime number or the one that is really driving problems in other areas. But, you know, it's really clinical preventive medicine. That's what it is. We're really just going to talk to people who are at high risk about the things that affect their risks the most. And we're going to do it on the front end, okay? And hopefully catch these risk factors before the risk factors snowball into something dangerous down the road that mixes with the job risks and then takes them down a darker path, okay? So I am going to hand over to Sarah Johnkey, who, as many of you know, is an absolutely – she's a leader. She's an absolute leader in this space and is taking us all down the science alliance road. Yellow brick road, maybe? And I've been told we're better with sound if I'm up here. So I'm not trying to just stand above you all, but I hear it's better with sound this way. Yes, I'm from Kansas, so ruby red slippers seemed appropriate for a conference. And I appreciate that we have so many people in the room interested in this topic. I know that as occupational health providers, you know the basics of occupational health, but let me tell you, the fire service is confused often about what your job is. So when they come to get their annual medical exams, when we go later and they're like, oh, so do you have a primary care doctor? Yep, I get checked out every year by the doctor. And we're like, okay, is that your primary care? Oh, no, no, no, OccHealth. So when they're not getting information from their OccHealth provider, they think they're fine. They say, well, I'm cleared for duty, which means I'm completely healthy. Often that's not what that means. I mean, I'm not telling you anything you don't know here, but we're working to look at how can we get firefighters to build a relationship with a primary care provider to improve their health and to manage their health in a better way. And I do appreciate that. I mean, all the accolades about the science lines. I'm very excited that we're able to share that in this setting as well. Because what we're trying to build within the fire service, within the scientific community, within the health provider community, is people who are interested in this population who can connect. You know, you're all connected here. And I don't know if you'd be shocked or you would be not surprised by the number of fire departments that get their annual medical exams from just a primary care provider in the community. Often who don't know what an occupational health physical looks like don't know what 1582 looks like. And so we'd like to create a network of the experts, which would be everyone in the room, and have that group be able to talk to the scientists. I don't provide any medical care. I used to see clients as a psychologist, and it was not my cup of tea. Bless you all for doing that type of work. I would sit behind my desk and type. But I love science. So what questions do you have that we could help you answer questions? You know, what studies can we design to further inform your work and vice versa? We also want to connect you with the folks out there who don't know how to do the AHRQ health exams, who just got the contract for the local department and want to do something with it. And then also connect it to the fire service. Because there are so many questions. The medical community is very intimidating for most of the folks in the fire service. So how can we help connect the fire service with medical providers? So that's the science alliance. I hope even more of you are super excited to scan the QR code at the end and get your lifetime membership gift. Thank you! That's what I'm looking for! I tell people, you're joining. So we started this actually as a result of a FEMA-funded grant, where we looked at COVID and one of the messages we kept getting from the fire service, which I think was similar, you get a T-shirt. And we actually have March. So we will get you a T-shirt. You have your choice. We have Einstein with a fire helmet on with our logo. We've got RBG with a fire helmet. I could choose that up. But what we realized with the COVID project was that the fire service doesn't know who to go to often to answer those questions for them. And if we can create a framework of trusted advisors with different groups of settings and with different topical areas, then they will know when they need it, they'll have the group to go to for the people. And then we connect them with FRC, who has all the content. So the provider's guide was really developed not to inform all health providers, but as a resource for when you see a firefighter and you say, okay, you need to follow up with your primary care. Do you have any estimates on the percent that follow up with their primary care? Two percent. Yeah. It's very low. Because they think that you are their medical provider. So why would I need another doctor? Because clearly we all, you know, all of you do the same thing as all their primary care and every other physician they know, right? They don't necessarily know the difference. So this was designed. Mike Hamrock up in Boston originally created a letter that basically he sent home. This was brilliant. Every one of the providers he got, or every one of the firefighters he saw, he sent it home with their pay stubs. So it went primarily to their wives, who then saw the document and insisted that they go see a primary care provider. So we decided IFC, the International Association of Fire Chiefs, Safety, Health, and Survival section created this originally. And pulled a group together, designed what do we think a primary care provider, we had a couple primary care providers in the group, what do we think that they need to get information wise from this? Now we did an evaluation with it and there were some things that primary care folks really liked. There were some things they didn't. So we created version two of it. Version two really, it changes, we've changed some of, softened some of the language. They didn't want to be told what to do. They just wanted to be given here's the risk factors. And then we did look at highlighting what are the issues that are unique to firefighters? What should they consider as, what should a primary care doc consider as a risk factor, kind of a family risk factor type thing? What do they need to know about what someone does when they're on the job? And then also looking at, we know US Preventative Services Task Force is for general population. Are there things that we're seeing emerging data on in the fire service and data that we can keep collecting about what should we be screening firefighters for? And is there anything that we should be screening differently than the general population? Now, the development of the original, like I said, was a group that sat together for two very long days in a conference room in Florida and discussed what pieces do we want to get in here? When we did the evaluation, we found that there were some of the most popular things and it was, I thought this was surprising with primary care docs. The thing they loved the most was that it talked about behavioral health. They said, if you give me something that gives me permission to bring up how's your mental health, particularly with firefighters who are kind of hesitant to have that conversation, there's a significant benefit to that. We know from the data that we've collected, like if you look at the research on firefighter health, there was some data in like 90s, early 2000s, but really 80% of what's published in PubMed, 80.1% of the articles published in PubMed had been published in the last dozen years. FEMA started funding under their research and development a small five to six grants a year focused on firefighter health. And it's really created this like renaissance of firefighter health research. And so we know cancer, IARC just reclassified firefighting as a group one carcinogen. Of note, it's for men and women, even though we have very little data on women in the fire service. Brittany will talk a little bit about the data that we do have and some new publications that we have coming out, because I'm sure you're asked by your patients about women specific issues. We also have, they also said it was for career and volunteer, which is significant. Most volunteer firefighters don't get annual exams and also wild land structure. And there was a third one in that group, but so we do know several of the cancers. We know that mental health concerns, firefighters are increased risk for mental health concerns and cardiovascular events on the fire ground, typically with underlying cardiovascular risk factors. So, so the people like we talk about cardiovascular disease, we know that about half of on duty deaths are firefighter or cardiovascular events on the fire ground. So when we talked about that a decade ago, when the CDC put out the MMWR report on this, people were surprised. It seemed like, oh, it would be, you know, burning or falling through the floor, things like that. It's cardiovascular events. And so one of the recommendations of the, of the, of the provider's guide is to really screen thoroughly and treat aggressively, particularly Denise Smith from Skidmore has been doing a lot of work looking at hypertension and even subclinical hypertension and the implications for firefighters. Cause really being in a fire is the perfect storm for a cardiovascular event. People are typically wearing about 40 ish pounds of equipment and going into an IDLH environment. So it's, it is the perfect storm. If you're going to have a heart attack, that's where you have it. And the work by Stephanos Kales has confirmed that most often the risk is on the fire ground, but also going to a fire and returning from a fire increased risk compared to being at the station. Recommendations that have been, that we have under the cardiovascular disease category is to really closely monitor cardiovascular risk factors, aggressively treat them, considering a coronary artery calcium scan or stress test at age 40 or earlier. Again, based on clinical judgment, but the recommendation from some work out of FEMA with Denise Smith at the helm has suggested that that could be very useful for firefighters. And we know that, so good news, bad news. We know that cardiovascular events are not occurring just at random, which I think for a long time was the message to the fire service. Like you have to be careful cause you might just have a heart attack. What we know from the NIOSH investigations on cardiovascular events on the fire ground is that it's not at random. It's typically people who have these risk factors. Now Tom Hales one time said that he was getting the complaint that the recommendations were the same for every NIOSH report of a cardiovascular death. He says, you know, they keep, you recommend the same things, get an annual medical exam, have a health and wellness program. And someone started to kind of give him a hard time about it. And he goes, when you stop killing firefighters the same way, I will stop making the same recommendations about how to prevent that. But really this is where it's important for the AHRQ health providers to, you know, you have this information. We need to be getting this information to firefighters and to primary care because there's a spadalistic sometimes, spadalistic, oh I'm going to die. There's a common belief I'm going to die within five years of retirement as a firefighter. That's not borne out in the data, one. But two, the other challenge with that is people are making their individual health decisions based on the assumption they're not going to live that long. So is drinking excessively really that big of a deal? Not really. You know, well, I'm going to get cancer, I'm going to die anyway. They're making health choices based on thinking that they're not going to live that long. And so I think that's probably playing into some of this. So there needs to be a lot of education around that. We do know Lee's work out of Florida is suggesting that firefighters are being diagnosed with cancer at earlier ages than the general population. And this was not based on clinic data. This was actually like registry data of things that were identified. And we know that PPE and gear does not protect against all exposures. A lot of times the assumption is, oh, well, you're wearing gear, you're wearing SCBA. First of all, often people are not wearing those as consistently as we would like. Recommendations now are that they wear SCBAs all the way through overhaul. Because research from UL has found that even when the air looks clear, there's still chemicals. And often they have the four chemical monitor where they say, oh, you know, there's not hydrogen cyanide, the carbon monoxide is down. And so they'll take off their SCBAs. Which what we know is that it doesn't matter if those, I mean, of all the chemicals that they're being exposed to, great, four of them are down, but there are all sorts of other chemicals that are out there that are not down. This was all the information, this and some research, epigenetic research that Jeff Burgess and his team have been doing out of Arizona were really integral to the IR classification of firefighting as a group one carcinogen. Now, in terms of cancer screenings and what we suggest be considered, some of them are more aggressive than what is recommended in the general population. Some of them, there's a lot of debate about what we should say people should consider, which is why we tried to very much soften the information. But one is the tracking PSA. There's a lot of work in the fire service trying to get people to talk to their doctors about their PSA. We also want to really encourage firefighters, don't go and get one test and consider that done. You need to be tracking that over time, which is why that's in there. But really, it's kind of thinking through. I give the example, when I talk to firefighters about, I had a brother who passed away at 36 of a heart attack. As soon as the funeral and everything was over, we went to our primary care doc and said, hey, I'm one of eight kids. So we all went to our doctors and said, I have a family history now. I have a sibling who died before the age of 50. What do I need to do? Everyone did something different. Everyone's doctors did something different with them in terms of screening. That's how we want to talk to firefighters about this. Like, you are at increased risk. This is like a family risk factor that you need to just make sure that your provider knows. They may or may not want to do the screenings that you're recommending, but they need to realize that this is a risk factor that you faced. And then on the mental health side, this was the favorite across the board of the primary care providers. We see rates of post-traumatic stress, depression, and anxiety about, depending on the study and depending on if you're looking at something post-disaster or not, relatively high. Generally double the population. There's a lot of debate in the fire service about whether there's an epidemic of suicide. Now, we don't know because we're not great at tracking it yet. There's work underway at the national level to start tracking that. But there was a survey of 7,000 firefighters put out by IAFF and one of the news outlets. And they had 7,000 firefighters respond. And about a third of them reported having some sort of suicidal ideation over the last year. So whether it's an epidemic, whether it compares general population or not, it's an issue for the fire service. And we need to be talking about mental health. And there's been a ton of progress. Like, if you talk to firefighters about mental health today compared to where they were a decade ago, there has been very concerted efforts to reduce stigma. It's not everywhere. We haven't made as much progress as we want. But there is a lot of conversation now going on about this compared to where it was a decade ago. So this is, in a lot of ways, we were talking this morning, like, this is our moment where I think we really are seeing a shift in the fire service, where instead of saying, you know, I was talking to Ellen Kessler this morning. I said, when you started your career, would you ever think there was a day where firefighters saw getting a physical as, like, a right, something the department owed them, versus something that they just had to do? There are now firefighters who are advocating in their departments and advocating at city council. We were just asked to put together a document to justify, here's why we need physicals for our department. This is, like, this is our moment where we can impact and make change on the fire service, because they are ready for it, and they're excited for it. Not all of them, but in general. We also see frequent binge drinking in the fire service. When there was a study that came out about the DOD and what the rates from the latest survey said in terms of binge drinking in my military folks, and it made front page news. So congratulations to all the DOD folks in the room. But let me tell you, our rates on fire service, way higher than alcohol use and binge drinking in the military. And it's probably not something to be proud of, but way higher, about half are consistently binge drinking. And when you ask them, is that a stress management tool? No. We did a focus group one time, and I asked that question. I said, do you think you drink to manage the stress of the job? Oh, no, no, no. He goes, no, I don't think so. This one guy's talking, and he's, I don't think I do. He's like, if I have a bad day or run some shitty calls, yeah, I'll have a couple of beers the next morning when I get home. I'm like, that is exactly what I just asked you. But they're not recognizing it as that. So I think that's one of the challenges. And I think if we said, hey, you shouldn't drink at all, you shouldn't drink alcohol at all, it would be laughed out of the room. But we do need to start thinking about that, and thinking about that as a cancer risk factor, as a cardiovascular disease risk factor, as impacting sleep. Definitely, we need to up our game on screening for behavioral health disorders and discussing them when you're seeing somebody popping positive on those. We know that sleep disorders and sleep in general is a challenge for the fire service. When you're working 10 days a month, and you're going to be up on calls. And I know there's the argument with shift work. Most of the research that's gone on about shift work has been in medical settings. It's nurses, it's physicians. We're working on that in the fire service. But we know from research that's come out of Brigham Women's that about, I think we're like 36% of the fire service screens positive for a sleep disorder, often undiagnosed and untreated. Where you do get, if you can get someone invested, and you probably need to get checked out for a sleep disorder, or be considered for a sleep study, you all of a sudden then see bunk rooms full of CPAPs. Like if you can get one person on board with they needed to get this checked out, they will let everybody else on the crew, everyone else on the shift, know that they've never had better sleep. So aggressively screening for sleep disorders and recommending follow up on that is going to be key. And helping primary care providers to understand this is going to be key. Because we're seeing people, when we look at, we did a study recently where we looked at shift 2448 versus 4896 shifts. And we thought we were going to look at the comparison of the differences in sleep. What we found was that people tend to come to work short slept, about 5.4 hours, and they leave work short slept, about 5.8 hours the night before they go off. Because they're getting up, because for 7 a.m. shifts, change time, they're getting up early and they're going to bed, or getting up early both days that they're going on and days that they're coming off shift. I mean, I don't have to tell you the importance of sleep, but to have consistently for 30 years, under six hours of sleep, I mean that impacts, I think really is driving a lot of the other health challenges that we're seeing in the fire service. So research is, more research is coming, and more research is needed, which is my favorite thing of all things, job security, really. And obviously, lung disease and issues with inhalation, again, because firefighters are not wearing their SCBAs the entire time. They're not wearing them, we tell them, wear it from the time you get off the truck to the time you get back on the truck. But there are all these other challenges too, and you know, gear, like I mentioned before, it's not designed, it's designed to keep you from catching on fire. It's not designed to protect you from the chemical exposures. There are some gear companies that are starting to do that. They have a product, a couple like Redline, and they basically have made it, and so all the contact areas are more self-contained, although that increases, you know, that increases your temperature too, like to be self-contained. But they really aren't, they are not all protecting of all things, so we know that. We know now there's a lot of things in the news right now about PFAS in gear. We know that there is PFAS in gear. We thought originally that that was stable and that it was in the layers, that it was stable enough that it wasn't coming off. There's some research to suggest that it is stable until you go in and out of fires over time, and it might be that that's dangerous too. Now, you might hear your firefighters talk about that, and they're very concerned about PFAS right now, which is a good thing. It's a great talking point to lead into all other things. There was a study that was just done out of Australia where, and Jeff Burgess is repeating this in Arizona, where they looked at PFAS in blood, and they found that if you, they randomly assigned to either a control group a plasma donation or a whole blood donation as consistently as you could, so I think it's what, 12 weeks or four weeks for plasma, and they found that you could decrease levels of PFAS in the blood by donating, regularly donating blood. So when your firefighters are worried about, they want their PFAS levels tested. That's why, because it's all over the news, and it's the gear issue. Now, PFAS is obviously not just in gear, but in every fire they fight, but that's what they're probably concerned about. So tell them to go get blood. We are developing some research, and Brittany's gonna talk about what we have on women in the fire service. Traditionally, this has been a severely understudied group because it's relatively low. The fire service is uniquely good at keeping women out of the ranks, but that's changing. So this is an area that's needing a lot more attention. And Brittany Hullerback. Thank you. I can't. Start singing. One place. There you go, your hand. Oh, it's on? Oh, I didn't have to do anything, okay. Hello, everyone. My name's Brittany Hullerback. I'm gonna finish up this session. We're gonna talk a little bit about the women firefighters specifically. And so unless you work in a clinic that is like occupational medicine specific, and even if you do, you probably don't see that many women firefighters because there are not that many women firefighters. Now, let's be real. There are like, so well, and we'll talk about the numbers here in a little bit, but women represent like nearly 10,000 firefighters across the United States. And so it's really important that we're protecting them. And we'll talk about recruitment and retention and how important that is to be able to support the entire fire service, right, including the women. But this work is focused specifically on women in the fire service. So Dr. Janke talked about the physician's guide that was developed for the fire service. And it has recommendations that are good for both men and women. But what we did was take it a step further and talk about some things that are gender specific. So highlighting women's specific issues. So I said, we talk a little bit about the numbers. Where do they compare to other occupational folks, right? So women represent about 13% of the police force, about 14% of the military, and even about 6% of the Marine Corps where everyone has to be combat certified, right? And then you look at the fire service and there's a bit of a range, right? So we see about 5% of women in the career fire service and that elevates to about 11% of the volunteer fire service. Did you know that women are two to three times more likely to volunteer in their hometown than men are? So very interesting. But I also tell you, if you are a researcher and you're trying to find volunteer women firefighters to do data collection, like I don't know where they are and the data says that they are two to three times more likely to volunteer and national statistics say that there are more women in the volunteer fire service than the career fire service and yet they're very, very hard to reach. And I think that speaks to the volunteer fire service and that's a whole different topic than today's discussion but it's of note for sure. Okay, so women in the fire service. Women have always been in the fire service but not as prevalent as perhaps around the 1960s, 1970s. Women really started to enter the fire service and part of that was due to some work by Brenda Berkman and the FDNY and there was a lawsuit and that started to bring women into the ranks of the fire service. And so research started emerging in the early 1990s and that looked at women specific issues in the fire service. And so this is why this is important as a provider. If you have a female firefighter come in, it's important to think about all of the risk factors that Dr. Janke just talked about but in addition, some of the things that she might be facing as a female in her workforce. And so the data has supported that women have these adverse issues as far back as 1993 and here's some of what it has said. So the study 93 was funded by FEMA and in collaboration with Women in Fire, at that time it was iWomen but it's one of the largest organizations of women firefighters in the United States. So what they found was that this was a yes, no. So 80% of the women surveyed said, yes, I have issues with gear fit. This specific to PPE but also uniforms and like station wear just duty pants and their polos and those types of things where 20% said no. Fast forward to 2008 and we can compare men and women's responses. So the dark gray 79% is women's responses. So this is women saying I have ill fitting gear. So 80% still from 1993 to 2008, about 80% are still saying I have gear that doesn't fit. Whereas 21% of men are saying I have gear that doesn't fit. So gear fit can be an issue for everyone. However, it looks much more prevalent among women. In 2017, you can see at the top there, we did a qualitative study where we asked women about the biggest threats to safety. And they said, one of the things they identified was PPE and gear and one of the, so my background is in the fire service. I was a firefighter for four years and then I went back to school and got my PhD in kinesiology. So my background's in like exercise science and a little bit of public health and behavioral exercise science. So one of the most alarming things to me doing these interviews and reading through the transcripts was that they said that their SCBA face piece didn't fit. If you know anything about the fire service, your SCBA face piece should fit super tightly because that is what's keeping out the IDLH atmosphere that Sarah talked about. That's immediately dangerous to life and health and environment, right? So that's like your literal first line of defense. Like your gear can be too long, but it's still doing its job. If your face piece is leaking, you are getting outside elements into the face piece. So it's very, very dangerous. And this was in 2017 that we published it. So I mean, we collected the data in about 2014 to 2016. So that's very, very current and this is an issue for women. In 2019, the USFA, United States Fire Administration came out with some recommendations and a wonderful guide, evidence-based. They're currently working with us and with women in fire to do an update to that guide. But the point is in 2019, they made recommendations on improving the size and fit of women's uniforms and PPE. And then there was a study in 2022 that found still 45% of women reported wearing men's size gloves. I don't know if you guys can see my hands from here, but I have tiny little hands. And not to say that all women have tiny hands, they don't, but gloves are one of the hardest firefighter equipment pieces to fit because everyone's hands are so different and they just make the, they're not very dextral and it's just very hard to find gloves that fit. And then it's even harder to find gloves that fit if you're a woman and you're trying to find men's gloves to fit you. And then, so yeah, so 45% reported wearing men's gloves and then 43% said they had difficulty finding gloves that fit, so that kind of makes sense. So we looked a lot at perceptions of gear fit and how that impacted injury, right? And we found that 45% of women career firefighters reported at least one injury in the past 12 months. 65% of women firefighters reported encountering problems with ill-fitting gear. So what are the odds of injury in the past year if we compare to those that reported very well-fitting gear? Well, for the folks that reported either poor or very poor turnout gear fit, they were 132% more likely to have sustained an injury in the past year compared to those with very well-fitting gear. For neither well or poor-fitting gear, so not well or poor-fitting, still 104% more likely to have sustained an injury than those with really well-fitting gear. And then even for those who said we had well-fitting gear compared to very well-fitting gear, there was a 49% increased risk of injury. So gear fit really does matter. Some of the other things that women mentioned in these interviews that were related to injury actually included discrimination and harassment, job stress and depressive symptoms were associated with injury. And we found this also repeated in our quantitative data when we looked at these variables. Now, this is cross-sectional, so we can't say like, oh, depression caused injury or injury caused depression. So it's important to remember it's not a causal or directional relationship, but these are factors that are associated with injury. And so I mentioned discrimination and harassment and how that can impact injury. And again, if you're wondering why it's important for you to know this, I think it's just important to understand the mindset of a female firefighter. And when she comes in for an annual physical to speak to some of the issues that she may be going through or to address some of these things and perhaps different screenings. We were talking with Dr. Koval the other day about what, it's so important to understand like the backstory, the baseline of the patient that you have coming in and understand what path to take, right? That decision tree. And so knowing some of this about female firefighters and where they're at, some of that can help you in your deciding the direction of care that you go. So in a study of nearly 2000 women firefighters, we found that women reported the following, this is the prevalent that women reported these incidents. So 41% reported shunning and isolation, 38% reported verbal harassment, 37% reported sexual advances. You guys, this is at work in the firehouse. And I think the most alarming one is assault. And so this is, it's not funny, but we were looking at the data and someone was like, we're sitting around the research table and we're like, okay, like this is interesting. This is interesting. And we're like, look, 5% like assault. Cause if you look at these bars, right? 5% is so low. And we're like, okay, this is great. And I was like, this is not great. No one should be, first of all, no one should be sexually assaulted at all, but you certainly should not be assaulted at work in a place where you feel safe. And the fire service touts itself as this brotherhood and this sisterhood. And it is, it's the greatest job in the world. So we need to understand why this is happening and also understand that as your patients are coming in, like this is something that perhaps she's faced. So furthermore, this discrimination and harassment can impact women firefighters' health. What we did was we took this study that I was just telling you about of this nearly 2000 women firefighters and we categorized them in a tertiles based on their reported level of discrimination and harassment. So you can see the code down there in the right. Red says they often, they reported often being discriminated or harassed against. Yellow is moderate discrimination, harassment and blue is never reporting discrimination or harassment or never experiencing. Okay, so then if we look at current depression, anxiety, PTSD and injuries, you can see that those who experienced often discrimination and harassment were like three times more likely to experience adverse health effects. So depression, anxiety, PTSD and injuries. The bottom line is that increased discrimination and harassment led to worsening health. What's interesting is that when you stratify them again based on levels of discrimination and harassment or severity of discrimination and harassment, you see that mostly folks are still happy with the choice to become a firefighter. Everybody loves this job. Like it decreases a little bit, but between the folks that reported that they were never discriminated and harassed against, 93% say they still love the job. Whereas 84% of those who experienced often discrimination and harassment were still happy with their choice to be a firefighter. Where you do see the decrease a little bit is when asked if they would recommend the job to another woman, folks that didn't experience a bunch of discrimination and harassment were more likely to recommend the job than those that did experience discrimination and harassment. So I think that's an important recruitment and retention piece there. So even with negative experiences, women still love the job, but it's important to remember that as they come in. One of the things that we have been asked about the most is reproductive health and spoiler alert, we're talking about women, but reproductive health is an important note for firefighters for both men and women. We're seeing negative health effects as far as reproductive health and fertility and conception for men and women in the fire service based on some of the things that they're facing. So this is an important note for your female firefighters, but it's also an important note for firefighters in general. So we have done a study that found increased rates of miscarriage and preterm labor among women firefighters. On average, we found that women firefighters have 33% lower levels of anti-malarian hormone. It's a measure of ovarian reserve and can predict fertility. And so we did find that women firefighters actually have lower levels of this anti-malarian hormone than non-firefighters. And then interestingly, we just did a study in collaboration with Dr. Burgess and the group out at the University of Arizona and found that volunteer firefighters have even lower levels of anti-malarian hormone than career firefighters. And at first, this was kind of confounding to us. We thought, hmm, I think we picture career firefighters are more often fighting fire and they're more exposed. And so perhaps they would see this lower level of AMH. And then we started talking about it and we started talking about the resources that volunteer firefighters have available to them and how often they're wearing old gear or gear that doesn't fit, or perhaps they're not getting annual physicals, they're getting biannual physicals, or perhaps they're not getting department-mandated physicals at all. And so thinking through whether your client is a volunteer or a career firefighter and what exposures they may have is really, really an important piece. Of course, there's exposure to toxic products of combustion, carbon monoxide, PAHs, PFAS, like Dr. Jenke mentioned. Certain chemicals and metals can be absorbed faster by pregnant women. So this isn't just thinking about prior to becoming pregnant. You might encounter a firefighter who is pregnant and is deciding, when do I come off the job, right? And so there's a lot of different things to think about with the dangers of her job. And some toxins may be more dangerous to the fetus than they are to the mother. So you have to think through the whole, all the things that are going on. Of course, circulation is upregulated during pregnancy. So the fetus may be, again, at an increased risk. And then just some things to think about with the fire service environment, right? So I think a lot of people perhaps look at firefighting like, okay, it's a difficult job, it's physically demanding, but there's an intense thermal environment, right? And that can impact a lot of epigenetics that's going on. It can impact conception and fertility as well. The loud noises can impact rates of miscarriage and preterm labor, physiological and physical strain, and the psychological strain as well of the job. Dr. Jenke mentioned earlier, gear can weigh anywhere from 45 up to 75 pounds. That's just your standard equipment, right? If you put on bunker pants and coats and your boot and your helmet is really heavy and then your air pack, you can easily be wearing an extra 75 pounds of gear. We talked about ill-fitting protective equipment and just in relation to health and injury, but then thinking through being able to protect offspring as well or a growing baby. And then the shift work, shift work can impact your reproductive health. And then there's a wide variation in pregnancy policies. So we asked departments. We asked women. Does your department have a pregnancy policy? Pregnancy slash maternity leave. I think it was two different questions And the point was 30% of women in our study reported that their department had no pregnancy policy So a lot of women that we talked to They're the first so if they got pregnant on their department, they are the first trailblazer for that department and they are Trailblazing every decision every path. When do they come off the line? What kind of policy do we have? What kind of leave do I have and they're helping their department kind of shape this policy. So it's like Most women we talked to are like, well, I'm I'm glad that I was able to contribute that but it sucks that it was Sorry, it sucks that it was me that had to do it right like I wish this had already been in place All right. So this is the last slide for me This is so NFPA 1582 is the standard for medical evaluations in the fire service and the 2022 edition has this wonderful edition of this chart and so there is an actual chapter I think it's chapter 9. Yes, and There's an annex with more information So this is the most reproductive health that's been available in the NFPA standard to date So it's very very exciting as dr Jenki mentioned there's been so much research done over the past dozen or so years And so it's awesome that we're able to incorporate this evidence into the guidelines So think through using the NFPA 1582 guidelines as a baseline for your recommendations The recommendations are quite similar for first through third trimester Of course in the third trimester, we know that there's increased risks based on fetal position But heat noise exposure to heavy metals These are all things to think through as the woman progresses through the stages of pregnancy and then Lactation is an additional risk. Dr. Burgess out of Arizona has done some research looking at breast milk and Poly diphenyl ethyls as well as a HR in the breast milk And so after fighting a fire does the breastfeeding mother pass any of the toxins on through the breast milk? And in an initial pilot study, it looked like perhaps she was passing some of those things on and they were present in the breast milk However, in a larger study, it looked like that was not the case And so it was perhaps safe to breastfeed. So at this point, we're giving the recommendation of Try It's so hard to tell a nursing mother that to throw out breast milk if y'all don't know it is like liquid gold And so we Hesitantly say to pump and dump for 24 to 72 hours post fire just to ensure you're not passing toxins along But the most current research doesn't look like there are chemicals in the breast milk after fighting a fire However, they only examined two categories of chemicals So that's important to remember and we need to do further research on that for sure But so as a clinician thinking through the pumping up conversation and when you're pumping and dumping and when you're fighting fire and how quickly you're coming back to work And so these are all really important considerations So with all that being said I don't know if Sarah wants to get up and do her dance about the Science Alliance because I know she's so incredibly excited Right and so there are some people that were incredibly incredibly excited, which is awesome So we as both Sarah and Elisa mentioned earlier We have this new organization or part of our organization called the Science Alliance The full name is science to the station the Health and Wellness Alliance. So get out your phones Scan this QR code use code ock health. This will get you a free membership free lifetime membership Which is awesome because eventually this is going to be a membership driven organization Meaning you're gonna have to start paying for a membership Part of the reason for that is to draw an excitement Sarah's found that people are more excited about things you have to pay for like buy into But also it's it's a sustainability piece, right? So our work is all grant-funded and we found that oftentimes Projects tend to die after the grant funding is over and we don't want that to be the case with this organization So eventually it will be So make sure you scan this QR code so you can be a part of this network get in for free while you can We're super excited to be implementing or integrating ock health with the fire service with health and wellness folks in the department with researchers Because that's what it should be is like this this hub. I call it like the Google for the fire service So, you know that if you don't know something you're immediately asking Google This should be the same thing Like if you don't have a membership and you don't have a fire service Or if I'm trying to get a job as a health and wellness person in a department Well, who do I talk to who's been there? Who's done that? What questions do I ask? What do I need to know like this should be your go-to. This is your like fire service Google And then our contact information, of course, so I'll bring back the QR code and then I'll send it to you and you can send it to me and I'll send it to you And I'll send it to you and I'll send it to you and I'll send it to you and I'll send it to you and I'll send it to you And I'll send it to you and I'll send it to you and I'll send it to you and I'll send it to you and I'll send it to you and I'll send it to you And I'll send it to you and I'll send it to you and I'll send it to you and I'll send it to you and I'll send it to you and I'll send it to you and I'll send it to you and I'll send it to you and I'll send it to you and I'll send it to you and I'll send it to you and I'll send it to you and I'll send it to you and I'll send it to you and I'll send it to you and I'll send it to you and I'll send it to you and I'll send it to you and I'll send it to you and I'll send it to you and I'll send it to you and I'll send it to you and I'll send 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