I'm Mark Leffer. I'm an Achmed physician. And actually, as I was walking in here today, I was just thinking to myself about the interesting path that it took me to come up here this afternoon. Now, as with many of us in occupational medicine, we all have interesting journeys. And I'm going to spend about five minutes going through mine. Mine actually starts actually with an IRA bombing in Brussels back in 79. But since that piece isn't on my CV, we're going to skip past that and go on to after I completed my family practice residency. After I finished my residency, I was fortunate enough to get an NIH postdoc fellowship at Health Service Research at Johns Hopkins. But from there, like a lot of us, my wife and I had two children. And I realized that I had to earn some money to support these kids. And so I was a full-time ER doc. About three or four years later, I found myself as chairman of ER at a place called St. Mary's Hospital in Leonardtown, Maryland. And I said, oh, good. This will be good for a while. And the CEO of the hospital came up to me and said, as long as I move my family out of Baltimore, where they were in private schools and all that kind of stuff, and move everyone to Leonardtown, she would give me the ER contract personally. And I don't know why it took so long. I waited for two minutes, and I said, no, thank you. And she said, OK. And three months later, she got a new ER group to come in. So now I'm unemployed, walking around my neighborhood when I run into a physician friend of mine who I had helped train in emergency medicine a long time ago. And I told him my situation. And he said, oh, don't worry. Take my job, because I'm medical director of downtown Baltimore for Concentra, and I'm going to now work for Blue Cross Care First. And I said, fantastic. I'll take your job. What's Concentra? So then he said, oh, yeah, don't worry. They do occupational medicine. So I said, great. What the hell is occupational medicine? But in any case, I took the job. And then about three years later, I moved over within Concentra to become center medical director of a facility in Columbia, Maryland. And that department took care of the Howard County fire people. And so that's how I got involved with Howard County Fire. So after my time at Howard County with Concentra, I moved on to the federal government. And I worked as an occupational medicine consultant for multiple agencies for about 10 years. The highlight of my time there was when I was asked by National Science Foundation to fly out to the South Pole to review the setup that they had for all their scientists at McMurdo and actually the pole itself. And I said, great. And so I had a great time at the federal government. After the federal government, I found myself for a Mid-Atlantic hospital corporation called MedStar. Now, there, actually, I helped work with their urgent care centers. And I also started up their occupational medicine business line. After that, a friend of mine who was trying to work out an RFP for the U.S. Postal Service, Achmed, calls me up and says, please write this RFP with me. And so the long and short of it was I got the RFP. And so I was the lead physician overseeing a group of about eight Achmed docs. And we were there to oversee the health and productivity of all U.S. Postal Service nationwide. So we signed this contract in December 2019. And two months later, we had become COVID central. And basically, we were overseeing the return to works for all COVID-related, for all 500,000 employees of the U.S. Postal Service. The highlight of that was the summer of 2020. I know timelines get mixed up. But the summer of 2020, we were basically working 24-7 with our whole group overseeing everyone to try to get everyone back to work as efficiently and timely as possible. And what was interesting was because us as a group were able to keep everyone back to work, all the mail-in ballots for the 2020 election were completed on time through the U.S. Postal Service. Then after the U.S. Postal Service, Concentra called me up and we had talked. And I said, we just got the contract for Montgomery County. Would you like to come back and work with firefighters? And anyway, that's why I'm standing up here and talking to everybody now. So Montgomery County Fire and Rescue. I have no financial disclosures, but if someone would like to give me some Bitcoin at the end of the lecture, I'd be happy to accept it. Concentra Occupational Medicine. Employee Engagement, Occupational Medicine, one patient at a time. Concentra. So, of course we belong here. Whenever I sit in a lecture, I like to know the answer before the lecture actually starts. So I'm telling you now, the final answer to this lecture on the last slide is, of course we belong here. So about 14 years ago, there was an AOHC conference in Los Angeles, not far from Fox Studios. And so I was out to dinner with a couple of my colleagues, and at the end of dinner, we decided to walk back to the hotel. And as we're walking past the hotel, we're actually walking right past Fox Studio. So of course, I turned to my colleagues and said, why don't we try to get into Fox Studio now to see if they'll give us a private tour? And my friends just went along with me because they knew better. So I walked up to the guard at Fox Studio Place. It was about 6.30 at night, and I said, hi, we're three AHCMED docs, and we are at a conference down the street. Would you mind giving us a tour of Fox Studio? So the guard looked funny a little bit, but then he looks down at his paper and he said, you know, there's a group of AHCMED docs in a party right here in Fox Studio now. Do you think you guys belong here? And I looked at my two colleagues, and I said, of course we belong here. So it turned out that it was a party for the vendor group called SOS. And so we got to the front door of where the party was, and the guy there at the front gate with all the names said, I don't see you guys on the list. Are you sure you guys belong here? And I said, of course we belong here. The party, I don't know, the party was amazing. Flowing champagne, a four-piece string quartet, black tie. I mean, it was a pretty nice party. About 45 minutes into it, I turned to my two colleagues who, I mean, were used to me by now, and I said, why don't we take that private tour of Fox Studio now, now that we're already inside? And they said, no problem. So we started walking around on all the different sound stages, and there was one door open. So we decided to walk in, well, I decided to walk into the open sound stage in Fox Studio. And this is a few years ago, but it was actually the sound stage for the TV show called Bones. I mean, it was pretty popular. That was a long time ago. Anyway, we're walking around for about 45 minutes. We're having a good old time, and then all of a sudden, at one end of the sound stage, two large garage doors open, and three golf carts come with six guards. And basically, they just come forward to us, and they say, are you sure you guys belong here? And I said, of course we belong here. They still threw us out of Fox Studio at that point, but it just is what it is. So again, I said, after I got thrown out of the ER because I wouldn't move my family there, I got over to Consentra through a friend of mine, and I wound up overseeing Howard County Fire in Columbia, Maryland. Now there, they were doing nine-minute met stress tests, cardiac endurance, in terms of their early periodic exams anyway. And at that point of time, NFPA had just come out with a new recommendation that firefighters should hang out on the treadmill for 12-minute mets instead of nine-minute mets. So I said to the guys, okay, here's the new recommendation from NFPA. You guys are already doing nine. We're going to do 12 now. Now it was at this point of time that actually, that Dr. Patterson was a vice president for Consentra. And I called him, and I had multiple talks with him, because I was just making this up on the fly. And I said, what do you think about this idea of making everyone do 12 instead of nine? And he was very encouraging. I mean, really encouraging. And unfortunately, he died before this project was done. And that's sort of the time frame of what happened. So anyway, we did it. All but two completed the 12-minute mets. Those two retired from disability anyway. And now out of those 260, about 30 of them had to come back two or three times to get up to the 12-minute mets. I know because I did them all myself. But no one cared. They knew that the whole idea is we weren't there to fire anyone. We were just there to get their cardiac endurance required up to 12. I mean, if they could be at nine, I mean, they could all do it. They just had some of them work their butt off to get there. And everybody did it. And what they found was because of getting that cardiac endurance up to 12 from nine, the recordable injury rate for the entire department dropped 40% with an ROI of 4.6 to 1. Now again, this is a long time ago, but we published this in JOEM in, I think, 2010. So that's what happened there. So I said, after I worked at Howard County, then I went to the federal government, and then I worked, the highlight was working for the NSF. So it's fascinating. To get to South Pole, you fly from Christchurch, New Zealand, to McMurdo, and then from McMurdo to the Pole. Now this whole operation was run by the New York Air National Guard, just north of West Point. And they were about 50% EMTs from the city and 50% EMTs from Boston. And this was about the time of the New York giant, New England Patriots Super Bowl. So they fly C-130 prop plane, military aircraft transport all the way. Now, if anyone isn't familiar with one of these C-130s, basically the front cockpit, it's just a huge glass window for the whole cockpit of this thing. So I'm on the cockpit of this flight, flying from McMurdo to the Pole, beautiful sun, amazing view of everything, landing at the South Pole. And meanwhile, the eight idiot EMTs in the cockpit with me are screaming at each other, trying to decide who has the better football team, the New York Giants or the New England Patriots. But that was my exercise there. So after the federal government, I said, I went to MedStar for a while. Then we walked to U.S. Postal Service and got mail-in ballots for the 2020 election. And then out of the blue, Concentra, we had another conversation. And they said, hi, we just got the contract for Montgomery County Fire back. Would you like to play with firefighters again? And I said, I would love to play with firefighters again, but I'm letting you know right now, I'm sorry, if I come back, I'm going to do what I did at Howard County and push it from 9 to 12 minute cardiac endurance. And they sort of squirmed, but they gave me the job anyway. Don't ask me why. So basically, the data that we were going to, sorry, back up before the data. So I told Concentra that I was going to do this, but to actually do it, as we all know, it's called politics. And so I had to get permission and buy-in from all the different groups, from the Concentra administrators, from the Montgomery County administrators. Now there's 2,600 firefighters roughly in the department, about 1,300 volunteer and 1,300 career. So I also had to get buy-in from the volunteer fire chiefs, from the career fire chiefs, and then, I mean, down the line for all the firefighters on the career and the volunteer side. Somehow, without Bitcoin, I was able to get buy-in. So the data that we collected, the nurses actually collected, was all pretty standard, date, age, gender, and then if they were career, volunteer, or applicant, and then the MinuteMet's completed. So the setup. We started increasing this to mandatory 12 MinuteMet cardiac endurance as of July 2023. Now in Montgomery County, in terms of the setup, all the fire stations have their own gym. And obviously, just like everyone, everyone's encouraged to exercise. On top of that, on the career side, all the insurers that pay the health premiums for the firefighters gave out, if they wanted, free FitBits on the career side. And basically, they were able to get $500 a year reduction on their deductibles if they obtained certain metrics on their FitBits. So that was one interesting thing. Then on top of that, when Concentra came in, they thought strategically and they hired a full-time exercise physiologist to do nothing but work with the fire department in terms of exercise regimens, in terms of diet, in terms of stretching, everything to try to create healthy firefighters. So in terms of the setup, everyone would come in, career and volunteers, for the early periodic exams. I mean, they're all on their schedule anyway. They'd come in, they'd get their exam, and then the last piece, they'd be required now to do the 12-minute, 12-minute stress test. And after they finished that, they'd come to me or the other providers to talk about what was going on. And the key was, as of July, if someone completed all 12-minute Mets, I mean, thumbs up, pass, Bitcoin, whatever they wanted, for the folks that did 11-minute Mets, 10-minute Mets, or 9-minute Mets, since this was a new system and a new thing going on, we conditionally passed them for the whole first year. We're saying, you're going to pass this year. And we gave them the contact information for our exercise physiologist, which was voluntary. We said, you're going to have to figure out how to get in a little bit better shape for next year. Feel free to reach out to this exercise physiologist if you want, because he can definitely help you, and we'll take it from there. So, and that's how it's been going since last July. 12, 11, 10, or 9. Now, on top of that, we just sort of held our fingers crossed. And we didn't pre-tell anyone about this new change when they showed up July, because we didn't want to get feedback to sort of stop it from starting in the first place. We were just hoping that once we get it started, people, I mean, Horton effect, people would talk to each other, and we were hoping for an improvement. So, hook. So this is my conversation with every single firefighter. Hi, I'm Dr. Lefter, and our group just recently got over here. All I can tell you so far, after being here a few months, is that we know it's going to take 10 years to work out all the politics of the great nation-state of Montgomery County. I've done a bunch of stuff, and at one point I took care of Howard County fire. Here's my card. So I know something about fire, and my job, as far as I'm concerned, is just to keep you all as healthy as possible, because if you're doing this job, then we should keep you healthy enough to get 40 years of retirement benefits, period. Okay, so going through the history, how much exercise do you do? Okay, here's the key, guys. I don't care about the word exercise. In fact, I don't like the word exercise. The key for long life and 40 years of retirement benefits is 30 minutes of moderate activity daily on your Fitbit, and here's the key. I don't care what that activity is. It could be walking the dog, chasing the kids, working on your farm, mowing the lawn. I don't care what it is. I don't care about gyms. I just need you to do 30 minutes of moderate activity daily. Now, why is that so important? Well, as we all know, all of us, our weight goes up in town a couple of pounds all the time. It's just part of life, but here's something you probably don't think about. Every time you lose two pounds, if you're doing the daily activity, and that's great, you lost two pounds of fat. The problem is, if you're not doing the daily activity, when you lose those two pounds, you can be losing a half ounce of cardiac muscle, because when your body needs energy, which is the definition of you losing two pounds, your body could care less where the energy comes from. In fact, it prefers muscle than fat, but if you're doing the 30 minutes of moderate energy work all the time, every day, that's cardioprotective. The heart says, stay away from me, and that's basically how you keep energy and be able to keep heart healthy, and whatever you want to call it, and get the 40 years of benefits. Oh, so I see you finished your 12-met stress test. You did it. Congratulations. Here's Bitcoin. Any problems with it? No? Well, good. Just FYI, you can blame me for it switching from nine to 12. Again, here's my card. I was at Howard County a long time ago, and at that point, NFPA had just increased the recommendation from nine METs to 12-minute METs, and I had everybody do it there, and when they did it, 20 or 30 of them had to come back two or three times until they got their endurance up to 12-minute METs, but again, that's okay. We're not there to fire anyone. We're just there to mandate that everyone increase their cardiac endurance, but sir, I'm a 50-year-old volunteer firefighter, EMS only. Perfect, sir. So forget about fire. You're in an apartment building, and you have to get up five flights to get the patient up and then frigging bring them down, so I don't think the steps care if you're 30 or 50. You're still going to have the cardiac endurance to get that patient up and down. Oh, and sir, the other piece about it is you're worried about age as an excuse. Well, we've already completed about 800 of these, and out of the 800, we figured out so far that first of all, 85% across the bat were able to do the 12-minute METs the first time around, but here's what's really interesting. We broke it down by age, or I broke it down by age because I didn't have anything better to do, and no one was giving me Bitcoin yet. Up to age 30, 87% completed 12-minute METs the first time. Now, here's where it really gets interesting. Age 30 to 40, 92% completed 12-minute METs the first time. 40 to 50, still 82% completed the 12-minute METs the first time. 50 to 60, now a smaller denominator because as you guys know, a lot of firefighters retire between 50 and 60, but out of the people that were left, still 80% were able to complete 12-minute METs the first time, and I'm not making this up. Age 60 to 70, I mean, there was only like 25 of them, but out of that group, 62% still did the 12-minute METs the first time, so sir, volunteer, firefighter, EMS only, I don't want to hear age as an excuse because it's irrelevant to what we're talking about. Now, here's the data, and I'll go through with this slowly because we did, by February 22nd, we had completed 777 12-minute MET stress tests. Out of those, only six didn't complete 9-minute METs. Out of those six, three were applicants that didn't become firefighters, and the other three were current firefighters with other cardiovascular things going on, so we're leaving that out of the discussion. So other than that, all 771 did at least 9, 10, 11, or 12-minute METs. Now, all this stuff about career versus volunteer, so up on the left-hand side, 92%, in parentheses, 92% of all career firefighters did the 12-minute METs the first time through. Then following it along, 1% of the careers did 11-minute METs, 2% of the careers did 9, actually 10-minute METs, and 5% of the careers did 9-minute METs. On the volunteer side, first time through, 78% of the volunteers did 12-minute METs the first time through. But here's what's interesting. Then in terms of 11 and 10-minute METs, on the volunteer side, there were 4% 11 and 6% 10. So if you add four and six is 10, so actually 88% of the volunteers first time through did 10-minute METs or more. And then the last 12% did only nine-minute METs. Now here's what we were hoping for, and we got it, the Horton effect. So again, when we started this procedure, we didn't tell anyone in advance, but we were hoping that people would tell each other. And either one, they were gonna take my card and get me fired, or number two, they were gonna try to get in better shape so that they would pass this test. And that's what they did. Because the numbers below on the career side, the 92% for the next, I'm sorry, this is the next 300 exams that we did since February 22nd. And I just sort of did it on my back of a napkin just to see how they were doing. The next 300, the 95% is what it went up to in terms of the careers getting through it the first time. So again, it's not, I didn't add the 300 to the previous 777, it's just a napkin view of the next 300 to see what happens. They got up to 95%. On the volunteer side, where it had been 88% first time through, now it's 85%, with the Horton effect of the next 300. So, now, here's where it gets interesting again. Again, I decided to break it down by age so that I didn't wanna hear any more of oh, I'm too old to do this. So, look at the non-parentheses numbers first. Across the board, 84% all the way to the right at the top, 84% did 12-minute METs the first time. And sort of I repeated a little bit what I did on the age, out of the parentheses, 87% initially of the up to age 30 did it, 91% completed 12-minute METs in the 30 to 40 range, 81% of the 40 to 50 age group, 77% initially of the 50 to 60 age group, and then 62% of the 60 to 70 age group, and we had one 76-year-old that did all 12-minute METs. It just is. But again, when I then did my napkin thing for the next 300, again, so this isn't 300 and putting all the data together, this is just the next 300. The under 30 group, actually up to age 30 group, went from 87 to 95%. So 95% of the last 300 did it the first time through. Age 30 to 40 group, it went to 94%. Of that 300 did it first time through. 40 to 50 age group went up to 83% doing all 12-minute METs the first time through. 50 to 60, that 77 went to 84% the first time through. So Horton effect's pretty good. And actually, to show that I'm not making this up, the 60 to 70 age group did drop from 62 to 50%. And I don't have an explanation for that yet. But again, let's see how injury rates compare with all this stuff. So we looked at monthly injuries for the department starting the year before we got there to then the year we got there in 2023 and the first couple months of 2024. So, okay, then these are monthly injuries. I mean, so they're not rates, but they're whatever. Injuries per month, if we want to say it that way. So, I mean, the blue or purple line, in case you're colorblind, obviously that's the year before we got there. Now, basically, consensual arrived in January 2023. And so that's the yellow line there. Now, we started the intervention making everyone do 12-minute METs in July of 2023. But again, we didn't have any Horton effect because we didn't let any know in advance. So from my talking to all the firefighters, by September, so two months into the intervention, in general, the firefighters were hearing about this in advance. And since they weren't trying to get me fired, they were trying to get in better shape to actually pass their physical. So basically, on this thing, the September 2023, you can sort of see the line drops as the numbers are getting lower. It looks like things are improving. And then, again, small sample, all injuries, the green line there for 2024, at least for January and February, the numbers seem to drop a lot more. So again, I'm not declaring any statistical significance for this numbers yet. I mean, we're continuing to do data and stuff, and we'll see. But at least so far, it's good in terms of showing a trend for decreasing injuries on top of everything else while going to required 12-minute, 12-MET cardiac endurance. So, conclusions. Out of 2022 NFPA, a minimum of 12-minute METs of cardiac endurance is required to complete all necessary firefighter duties. Just pull that out of the appendix, 2022. Second, this isn't for career and not for volunteer. All career and volunteers have the capability of reaching the 12-minute MET cardiac endurance level. And age, that's nonsense too. Firefighters at any age, as long as they're alive, I mean, have the capabilities of completing 12-minute MET cardiac endurance across the board. And again, the final 12-minute MET requirements of cardiac endurance in Howard County show definite statistical significance for decreasing injury rates. And even for Montgomery County, shows early trends for reducing number of injuries by forcing everyone to get to the level of 12-minute METs of cardiac endurance. So, moving forward. As of July 2024, it's gonna be a full year. And our plan right now is that it becomes mandatory for everyone to work as a firefighter to complete 12-minute METs. Now, this is how we're gonna do it. Everyone's coming in for their exams anyway. If they complete 12-minute METs, they get Bitcoin, they get thumbs up, and they get out of here. Anything less than 12-minute METs, we tell them you've got another three months to get into improved cardiac endurance to be able to do it. And we give them the contact information for our exercise physiologist. We'll say, if you wanna work with her, fine. If not, we don't care. But you gotta get up to 12-minute METs. And for those that don't, after three months, then they get put on light duty. And we send them to our training facility and tell them to come back when they're ready to complete the 12-minute METs. Now, saying that, on the career side, I mean, just because of the other effect, we were up to 95% anyway, completing it the first time. And we think that the Horton effect is gonna just continue to increase as more and more people talk about it. And I know more people are talking about it. So, on the volunteer side, we have to treat everybody the same. So same deal, they're required to complete 12-minute METs of cardiac endurance. Same deal, if they don't, they get three months to work out, do whatever they wanna do. Even though they're volunteers, they get the contact information for the exercise physiologist. They can voluntarily work with her if they want. And the only difference is, if they don't get to 12-minute METs of cardiac endurance at the end of three months, then they're put on not-fit-for-duty. But here's the deal. We're not saying you're fired. We're saying you're not-fit-for-duty until you can come back and show the 12 minutes of cardiac endurance. And then you're back on the job. So, the business of medicine, and here's why I find it's really interesting. Quote, unquote, follow the money. In the US, there's two major business lines for medicine. The first one is looking at the health of the patient, and then with revenues equaling the total healthcare services provided to those patients or individuals, whether it be doctor visits, ER visits, hospitalizations, surgeries, pharmaceuticals, or medical devices. Now, the problem with this business line is that the incentive of keeping a patient healthy is not at all necessarily linked with revenue stream based on patient services. It just isn't. Now, here's something that they, I'm sorry, think about, a different business line where you focus on the health of the patient and the revenue stream is based on cost savings to the employers who are paying the healthcare premiums and the extra hospitalization costs and the workers' comp costs for their patients. Now, in that business model, same amount of revenue, but it's all based on cost savings, and then the health of the patient is totally aligned with the revenues derived from cost savings. So again, as I said, I mean, do you think we belong here? Think about the fact of us as all being occupational medicine providers. Who is in better shape than anyone across the whole spectrum of medicine to be able to work with the business model of aligning improved health of the patient with a revenue stream based on cost savings to the employer, and the employer could be all companies, and government entities, whoever, military, whoever is paying for the health insurance. And I'm saying, who, I mean, do we belong here? Of course we belong here, and no one else but us belong here. So I'll stop talking, and now anyone can come up to the microphone and you can ask anything you want, and I might even be able to answer it. Well, thank you, Mark. That was a really interesting. Congratulations on the great results. I just want some clarification about the, I believe you said that one or more of the insurance companies were providing Fitbits to the firefighters with the possibility of earning $500, and I'm wondering what they were measuring. Were they measuring fitness or just activity? And then also, help us understand the timing of that relative to when you decided that you were going to increase the threshold up to 12 so that we can figure out what kind of impact the insurance company played in this whole process. No problem. Thanks. No problem. Montgomery County arranged this with the insurance companies prior to us getting there. So it had already been there. Now saying that only, I mean, it was voluntary. So some of the firefighters weren't taking the free Fitbits anyway. Now, every time I talked to the firefighters, I said, especially the career, because those are the ones that the insurance companies were giving them to, I said, I mean, do you have a free Fitbit? And probably 75% of them said yes, 25% of them said no. And I just said, well, I encourage you to get one, especially since I gave them the talk of the 30 minutes of moderate activity. So that was in place before we got there. The other thing that was in place before we got there was that they already had the gyms in all the facilities, and they were encouraging them to work out. And again, it wasn't like there was nothing going on before, but up until we got there, the only requirement was nine-minute METS, cardiac endurance, and not 12. The thing that was new from the time we got there was Concentra had the foresight to hire the full-time exercise physiologist to work with the fire department, like I said before, on exercise regimens, flexibility, and diet. So that was something that was new. So that started as of January, 2023. And then we got there, we started the protocol in July, 2023, and gave two months for the Horthvon effect to start by, here we go, Horthvon effect to start by September, 2023. So September, 2023 is really what it looks like when our initiative was getting measurable results. Thank you. One of the problems that is apparently present in NFPA 1582, the versions of that up until March of last year, actually called for different medical criteria for applicants than for incumbents. And that is a blatant violation of the Americans with Disabilities Act. Absolutely. The committee corrected that in March of, actually the Standards Council corrected that in March of last year. The issue about having METs as a requirement for firefighters is very questionable. It's questionable because, again, under the Americans with Disabilities Act, you are not permitted to have a medical requirement that is, unless it is essential to meet an essential job task. For every one of the essential job tasks of firefighting, there's been no demonstration that any one of those essential job tasks cannot be performed at a given METs level. So there's not a single one of the essential job tasks that can demonstrate that X number of METs has to be available or you can't perform it. The employment law attorneys that we have talked to have indicated that therefore having any MET requirement is quite likely a violation of the Americans with Disabilities Act. As a result, for all of the fire departments that I and the organizations I'm associated with provide medical evaluations, we don't do treadmills for any one of them. What we do is we do calcium scores and we do inflammation indicators, specifically an LPLAI-2. This comes back to one fire department, Seminole County. We had two firefighters that dropped dead. Pretty much one was 38, one was 42, six weeks apart. They came to us wanting to know what they should do. We suggested, well, number one, your treadmills aren't working. As everybody's aware, a treadmill has a 30% chance of giving you a false negative. So if you have 100 people going into the cath lab, 30 of them are going to have a negative treadmill test. So what we did with those firefighters, we said we're gonna do calcium scores. We're gonna do, in this case, we only did calcium scores. And of the first 150 that volunteered to do that, paid their own $100 to have it done, 15 out of the 150 ended up going on for cath, doing a stents or bypass. They had a 10% rate of occult disease, all of whom had passed their treadmill tests. So just suggesting that while I don't dispute that people that do better on METs are going to have a lower injury rate, I would suggest also people with lower BMIs will have a lower injury rate. But you can't hire people based on a expectation of lower injury rates. Mm-hmm. All I have to say is, I mean, it's a lot of, I totally disagree, and it doesn't make sense. And even in 2022, it says 12 minute METs of cardiac endurance is required to complete all essential job tasks. So cardiac endurance is an essential job task. And therefore, and then what's really funny with all this political nonsense with NFPA is if you look at any of them talking about coronary artery disease, and one of the things, as you know, for coronary artery disease, to be able to work as a firefighter anyway is to be able to complete about, able to complete 12 minute METs of cardiac endurance. And so it's gonna be interesting. Okay, well, the latest version of that that was passed in December of last year, unfortunately, calls for a different level of METs by gender and different level of METs by age. So essentially, if you are a 20 year old male, you're required to have 12 METs. If you are a 50 year old female, you're only required to have five METs. I don't think that makes any sense. And the bottom line to it is, for any one essential job task, anyone you wanna mention, there's not a single publication that says this is the number of METs required to do that task. If you can't demonstrate that, my suggestion is it would be prudent to talk to your employment law attorney before you adopt something that is quite likely to be an ADA violations. Thank you. So I don't have something as controversial as that. I don't know how to follow that one up. Anyway, so I live in Maryland. I was actually a volunteer EMS in Hartford County in the 90s before going to PA school. I guess my question is for, if you have volunteers who are no-goed and have to go into the remedial, I guess, health program, how does that, because again, I remember you had to run 50 calls a year in order to get a good year in order to go for your 20 years retirement, but again, on the volunteer side, does that, is that something, if they are no-goed and they are not allowed to serve, does that affect their good year until they're able to perform the task? Is that something that's been covered? I don't know if the same thing rules apply, but as soon, I mean, as soon as they're able to complete the test and they do it and they show that their cardiac endurance is up, they're back on. They're good to go. Now saying that based, I mean, there's gonna then continue to have the yearly exams after that, and, but we're not, we don't wait. They were held off, not to be fired, but just until they got their endurance up. The day they show that their endurance is back, they're back good to go without any waiting. So the volunteers were getting, they're getting yearly exams. Everyone, everyone, everyone, all 2,600 are getting yearly periodic exams. And again, it doesn't matter career volunteer, everyone up to age 30 and including age 30 gets the 12 minute met cardiac endurance stress test every third year, but everyone is getting the rest of the exam every year. Age 30 to 40, doesn't matter career volunteer, everyone's getting the stress test every two years and then 40 above, on top of getting the exam every year, career and volunteer is getting the cardio endurance 12 met stress test as part of their exam every year. So, and then, so if they can't pass, they get the benefit so that the county comes in and takes care of their deficit. Like it's not handled through their personal insurance because it's volunteers, they have their own personal insurance. If you're a career firefighter, your insurance comes from the county, correct? Well, again, the volunteers don't have that or they don't have that? On the career side, again, it's gonna, I mean, we're already down with, with Horton effect down to 5% that didn't do it first anyway. And I'm assuming with Horton effect, it's gonna be one to 2%. But again, career side, they're put on light duty. So just like any other injury, light duty, and they get paid while they're on light duty, just like they'd get paid if they were on light duty because they sprained their ankle. Right. And so, and then as soon as they get back up to the 12, they come off of light duty to full duty. So their pay, nothing changes at all. Right, but on the volunteer side though, volunteer side don't, they have the same benefits? They're volunteers, right? They don't work for the county. No, I mean, they don't work for the county. They have their own jobs, their own health insurance. It's, then it's on the case-by-case basis. But I mean. Okay, so it's a case-by-case. So again, if they're a no-go and they can't perform, they get a bad year. Well, it's not a bad year. They get a not-fit-for-duty. For, again, we called them retirement benefits. If you did 20 years of good year service for the county, you would get a benefit for that. I understand. I don't know the answer to that. OK. OK. Thanks. Hi. Thank you for that lecture. Great lecture. Are you aware of any new NFPA guideline changes that we've been hearing? And if you know, then can you share? And it's related to, apparently, physician-directed exams. All the exams now for the firefighters are required to be physician-directed. So I mean, so that's what I've heard. No, I didn't understand. I didn't hear. Are there any new NFPA guidelines that are coming up or have come up recently in last couple months for the firefighter exams that you are aware of? I don't know what's come up new in the last couple of months. I'm not directly tied to the NFPA. All right. Thank you. I mean, if someone else with NFPA can answer her question, that'd be great. I just don't know the answer to that. Hi. I mean, thanks for the lecture. I just want to find out, was there any relationship between the length of service and these injuries that the firefighters have sustained? That's a good question. And the answer right now is, I don't know. But what we're going to do, oh, the answer was, was there any relationship between age and the type of injuries that we charted the firefighters? The length of time the individuals have spent in the fire service and the injuries that they have sustained, whether there was any relationship. My answer is, I don't know. But as we get more data, that'll be one of the things that we try to study as well. OK. The other thing I wanted to find out is that, were there any relationship between existing medical conditions in these individuals and the injuries that they have sustained? Again, it's a great question. And we will, as we get more data, try to study that as well. But we haven't studied the specific injuries, other than counting them for now, in terms of trying to look at each injury to see how old they are, what other medical, concurrent medical chronic conditions they have. It's a very good question. And as more data, we will try to study it. We haven't looked at that as yet. I think the third question is that, my understanding was that there were some sort of adjustments to the oxygen output per kilograms per minute, according to age groups and all that. But what you're saying is that there's just one level for all ages and so on. Because it's the same fire. If someone has to get up five flights, and there's 100 steps, there's 100 steps in five flights. And so, I don't care about oxygen. I don't even care when we do the stress test. We don't even track. But oxygen output is what you are counting as to have met. No, what I'm counting. No, that's basically what it is, because it is about 40 mules of oxygen per kilogram per minute. That's what it is about. And what I'm saying to you is that, from our observations, working with firefighters and so on, where the amount of oxygen produced per kilogram per minute has been graduated to different age groups, there has not been any increase in the injury sustained by this individual compared to those who are doing 42 mules per kilogram per minute. I thought that that was a standard set for new firefighters. For existing firefighters, that was a slightly lower level. Well, first of all, with the latest version, we can't treat applicants any different from normal firefighters anyway. But again, when we do this BRUCE protocol stress testing, we don't even look at, we don't care about heart rate. I mean, we're not there, we don't care if they exceed 100% of the heart rate. All we care about is if, because we're doing this as a cardio endurance test, to make sure that they could complete. Well, the point is, this is what I'm saying to you. You are mentioning 12 METs. 12 METs is equivalent to 42 mules per kilogram per minute of oxygen output. That's exactly what it is. That's at the energy level. But we're not measuring that. We're measuring minute METs. In other words, as you know, in a BRUCE protocol, when you get to the 10th minute, you're on stage four, and then you're at an energy level of stage four. But we're measuring the time that they're at that level, because that's part of our cardiac endurance test, that they're able to stay for three minutes, BRUCE protocol normal, at that level of 40 mL equivalents, whatever you're talking about for the oxygen. So we're doing it as a cardiac endurance, and not just reaching a particular energy level. At what point do you stop the BRUCE protocol, when you look at a heart rate of this individual? We don't. You don't stop it? And you carry on? Well, until they say, I'm too short. Until they die? No. Is that? That's a good question. Until they die? Is that what you're saying? What I'm saying is. I'm a bit surprised to hear this, really. Well, listen, no. What I'm saying is, first of all, if someone's medium risk, we don't do it in the office anyway. I mean, we'd send them to their cardiologist to get it done. But in terms of otherwise, we just tell them, when you feel too tired or too short about to continue, say stop, and we stop right then and there. It's not when you feel too tired. There are set heart rates, as per age, that you get through, at which point in time, you stop the BRUCE protocol, you stop them from carrying out these exercises. Okay. I don't want to take much of your time and the time of the audience here, but I do feel that it's important that you look into these studies very well and ensure that the next time you're back here, I think we get much better clarifications. Thank you. No problem. Thank you. Hi, my name is Raj. Thank you for the talk and very nice to see some of the changes and the endurance of the firefighters. Quick question, just more for clarity, for implementing the exercise test, is this more of a treadmill stair test that you're just watching them do, or are you also linking them up to the actual exercise? Oh no, this is a true BRUCE protocol stress test. Yeah. Three minutes and we have the cardiac, everything is hooked up. It's no different from the tests that would be done in the cardiologist's office. Yeah. The only difference, and I'll say it again, is we don't care about max heart rates. I mean, again, we're doing this for cardiac endurance, so we're putting them through, and I specifically say 12 minute, Matt, because we're looking for the length of time that they're doing each level too. But it's the same machine that's in the cardiologist's office if they get it done there. Okay. The other, I guess, comment, question, going back on what the other gentleman brought up, with the NFPA bringing up some changes and recommendations, they issued it back in December. Are you recommending to implement those changes based upon what they're recommending per age group in the grid, or are you gonna stick with the 12 mets? And the risk, I guess, the issue that came up for our clinics is we have different municipalities, and they're reaching out, asking us to stop any stress tests, exercise endurance tests, because of these changes, and they want us to apply it based upon NFPA's recent issue statement from December. So, if you have any comment on that. Yeah, I mean, it's based on the jurisdiction, and Montgomery County, actually, Montgomery County currently is using the 2013 NFPA. So, we're not even gonna go there, but it's, and so, and there's a chief coming in, a new chief, so if they say we're staying at 2013, we're doing that. If they say, so I have to follow the guidelines that is voted on between the unions and the county, and whatever we say, we're stuck with doing. But the thought will be that they will push forward with the 2022, I mean, I'm saying that between your mouth and God's ears, or whatever the phrase is, but I'm just, whatever the county says is what we have to do. And they vote, and then we just have to follow their lead after that. So, I have to take this off. Looks like it's not tall people friendly. So, thank you for the talk, and actually, it's nice to see this reduction in the work-related injuries. I know that you said that you're still collecting more data about this, and maybe. Oh, it's ongoing, and so next year, I'll have 2,000 more firefighter stress tests done. I think my question is first, do you have a classification of those work-related injuries, and you see, like, you know, one specific injury is reduced more than the others, meaning related to the cardiovascular health versus, like, trip and fall, or something like that? As of right now, again, we've just started. We haven't gone into the specific injuries yet. Now, saying that, our full-time exercise physiologist with a PhD that's working on this is sort of ongoing. She'll see, a patient will have a shoulder injury, and she'll say, do this, I mean, she shows them different exercises to do. So, in general, we have someone that talks to the firefighters when they are injured, and I sort of hook them up, and she works with them voluntarily, if they want to, to minimize the risk of a similar injury happening again. I mean, this is really off the track a little bit, but some of the facilities play pickleball when they're working, pickleball. And so, the first four months that I was there, we had four pickleball injuries come in. So, I mean, do you say, well, I mean, obviously, pickleball is not a good thing. We should stop pickleball. Or, we didn't do that, but instead, we got our exercise physiologist to go in and to sort of see if they slipped on the court, or what was it, or were they diving head over heels, and try to work with the groups based on some of the injuries. And hopefully, next year, we'll have a lot more data, and I'll actually be able to give some information on specific injuries. What I'm trying to find is there a correlation between increasing them, it's from nine to 12, improving their cardiovascular fitness, so prevented specific injuries related to that, instead of collecting all the work-related injuries in one part, including other injuries that couldn't be related to that. It doesn't matter if you increase it from nine to 12, just more correlation about this. And this leads me to the second question, which may be a good thought to think about it, to correlate these trends to the number of calls that they responded to during the year, and also the number of shifts that they worked at, because this also could be a correlation factor, or something that could change these results a little bit. No, it's a very good thought, right, because as we know, especially the younger guys are doing a bunch of overtime shifts, and there are busier stations, and less busier stations, and in general, as we all know, usually the younger firefighters are in the busier stations, and as they sort of, now this is across the board, as they age, they usually, many of them get over onto the less busy stations as well. So it's complex, and there's a lot of things going on, but it's a very good question. Okay, thank you. Thank you. My name is Harleen Liu, I just, it's a really nice data set, thank you. My question is, number one, continue with the category of the injury. Any exercises induced injury? I'm sorry? Exercises induced, caused injuries. Exercise induced injuries? Injuries. Okay. Because some of the firefighters, they can do exercises at work. Absolutely, and we have had firefighters that came in because they strained their calf because they were on the treadmill. Yes, so that does happen, and it goes back to the folks that wanted to know where the injuries happened, because, I mean, getting to the root cause of each injury, it can be key, along with increasing cardiac endurance, to decrease the numbers overall. Because I do not know if you count those exercises induced injury or not, number one. Number two, do you have BMI data before and now? No. No. Okay, good. I think that will probably be a good, another parameter to add. Thank you, I like your thought. Dan Samo, just, one of the questions, where can we find out the latest and greatest about NFPA? Tuesday afternoon, we're doing a session which will go over all the newest stuff. I've been on the NFPA technical committee since 1991, along with my buddy back there, Fabrice. So if you want to know about what's latest and greatest, come Tuesday afternoon. Thank you. What room and what time? Oh, I don't, it's the two afternoon sessions. Two, okay. So another thing, this study, I did read your article, and I wonder why you didn't report that this intervention had no effect on any of the measures of wellness. Cholesterol, blood pressure, all that stuff, you said that there was no effect on that. So this program, which was initiated, I assume, as a wellness program, the one thing you found was somehow, miraculously, a reduction of injuries, which surface validity makes no sense whatsoever, which makes you think there must be some confounding factors. So the question is, what could be the county? Where did the injuries occur? Were they on the fire? Were there EMS? Because we all know the most dangerous piece of equipment in the fire ground is the stretcher. How does this correlate to the number of calls? Were there more EMS calls and therefore more injuries? And also, why the huge majority of your overage of injuries seems to be before, and they dropped off at the time that this started. So what was happening at the end of, in the spring of 2022 was COVID. Were they having a lot more ambulance calls? And that's why the injuries? It just makes no sense to me whatsoever that the reduction in injuries is due to a wellness program. It just makes no sense. And I don't think there's enough looking at the confounding factors and the things that really possibly could have done this to make this any kind of thing that we could rely on in any way. And part of the question we're gonna be asked about bias. So you're saying that this is an ROI of four, because of injuries. Is this a program that Concentra and you are being paid for by the county, or is this a research study that you're doing for free? Well, no, Montgomery County is paying Concentra to staff their Fromm's clinic, fire, everything. And I'm just the doc that is overseeing fire that initiated this program. See, to me, this seems like data dredging. You went back afterwards and said, well, we didn't affect the wellness stuff, blood pressure, cholesterol, blah, blah, blah. So how are we gonna justify this program? Oh, look what we found. This, it doesn't sit right, sorry. Will you agree to disagree? That's fine. Just to let you know, there is a white paper for volunteers within the petroleum industry. Several major petroleum companies. It's an AECOM. And went together and decided that, because we obviously have multiple different types of fire departments, depending upon where we're at, how much they're required. They did a study through Texas A&M, finding that there were several, and remember, this is non-structural. As a volunteer fire department in a petroleum industry, you do not do any structural firefighting. It is non-structural firefighting. So they do everything up to, everything else is done by the municipal fire department if they needed to. The study showed that there were four or five, and I remember the one carrying a charged fire hose, all required a minimum of 12 METs to complete. And it's, you know, those type of things. So there is some evidence to support the 12 METs as a requirement to do the job. I don't know if Texas A&M published that or not. I don't know. Don't tell Dr. Samuel that. And the other thing is, is that, as you know, when it comes to some of the health maintenance metrics, that may take a few years to really document one way or the other. You may not see in the short time this program has been in existence to really have enough data to really look at the health measurements of cholesterol, blood pressure, et cetera, looking at the long-term health effects of this type of thing. But there is data out there. There is a white paper. It was about 2017, I believe, was when it came out in ACOM. So just to know there is some information out there that does support the 12 METs, is a minimum requirement to actually perform some of these central job functions of firefighting. Thank you. And again, that's what, and that, when I pulled that line up, I don't know, that line from 2022 NFPA about, I mean, that came out of their appendix. So they probably went to the same white paper that you're talking about, or maybe another one. Hi, I'm Bob Flegelman. I'm Medical Director for Occupational Medicine Centers of America. We're based out of Florida here. So first question is, does Maryland have a heart-lung bill? I'm sorry, I don't know what that is. Blood pressure, heart, is automatically workers' comp when a firefighter gets it. I don't know. Okay, Florida does. Okay, so what we do is, for the firefighters on their initial hiring for their physical, we do a full stress test, 100%, okay? And it's to identify the baseline because we have found a number of them, okay, have heart conditions. So for workers' comp, that makes a tremendous difference. It doesn't mean they're not hired. They've got it on the job, or if they had a pre-existing. Right, okay. Injuries, okay, very few are related to that because with a heart-lung bill, if you develop hypertension later on, okay, it now becomes workers' comp. We take care of the workers' comp also so we see both sides of it, okay? We've been doing the annual stress test on the physicals. We use the 12 METs on that. 12-minute METs or different? 12 METs, okay, 12 METs. That's what they've gotta get to, all right? And then for some of them who really enjoy it, we let them go higher up and they can prove they have testosterone. But the majority of the injuries that we see, number one injury, stepping off of the fire truck, okay? That's the number one injury. Number two, I was playing basketball, okay, and I sprained my ankle. Not pickleball. It's coming, it's coming. We've only had one or two of those, okay? But basketball is the big thing. It's Florida, they play more basketball outside, all right? So I don't know how that would at all pertain to this. What we do do, though, is we compare them year to year. So we are able, because of the stress testing and how long it takes them to get to that 12 METs, we can now look at how they're doing and they become very, very competitive with themselves, okay, to do better the next time. Do we get them to change their cholesterol, blood pressure, all that? Yes, and I agree, it takes a while to do that. But if you're taking care of them for a long time, it looks like you're doing two and a half years here or two years and a few months, okay? I've been doing it. The original ones have already retired and I'm still working. Well, I just got here a year ago. So the first year before we got here. We'll just keep going. You can do that with it. Okay, does the 12 METs actually improve performance? I don't think so, okay? Because we can have them doing great on their stress test, but when they have to climb the stairs on their performance testing, they still have the problem. It could be their muscles, it could be their weak, okay? But if it's a cardiovascular factor. Cardiovascular factor. Endurance. It's endurance, okay? But there are so many other factors that play a role. Absolutely. Just a different way of looking at it. Thank you very much. Are we done? Okay. Thank you very much. Thank you.

Mark Leffert

occupational medicine physician

Howard County Fire

federal government

U.S. Postal Service

12-minute MET stress test

Montgomery County

firefighters

NFPA guidelines

firefighter health and safety