»» Okay. Good afternoon. So I think we have four topics. Whether we go over all four, I don't know. Dr. Samuel was supposed to introduce this, at least the topic, apparently not. So I will do the first. I am Fabrice Czernecki. My day job, I'm the chief medical officer for TSA, Transportation Security Administration. But I'm going to talk to you about that. And by the way, if you want to know more about these more political updates and the latest, join the Public Safety Medicine section. The chair of the section is right here, Dr. Gallade. The founder of the section is here, Dr. Samuel, and I'm the immediate past chair. And I'll tell you a little bit about my fire background in a few minutes. All the disclaimers, that's my opinion, my opinion only. And since some of us are in some of the NFPA technical committees, I think we have to give you the warning that, again, we're not talking on behalf of NFPA. The technical committee members are not allowed to give an interpretation. So what's in the document, you know, you read it. Your reading is as good as mine. So that's what I used to do at some point in my career before TSA. I was the medical director for Chicago Fire Department. On top of the ladder, that's me. And behind me, that's the head of safety. And by the way, the head of HR, when she saw that picture, said, you're crazy. You're not allowed to do that. That scene was actually pretty safe, I think. Okay, so let's talk about NFPA 1592. Is anybody using this document today? Ah, not many hands up. Lou, you're taking my picture? Okay, so you can't use that document, okay? So you remember one thing from the end, at the end of the lecture. This is, this paper document is obsolete, according to NFPA. Okay, so let's talk about some history of NFPA 1592, in case you're not aware of all the different steps, the changes that happened. So on, in April 2021, that's when this document, this printed document came out. At that time, the, I call that alignment, which is a pretty undefined word. That chapter six for applicants and chapter nine for incumbents would be closer to each other. There was a, I think, yeah, the essential job task, they added the PPEs everywhere. Okay, I just did a few other sections. That's the structure of the document at that time. Don't worry, that's not a test question. I'll tell you what's in it now, which is probably more important. Okay, then in April 2023, NFPA came up with what's called a TIA, a tentative interim amendment. So that's an update of the document. Amendment, by the way, has to be urgent, has to prove that it's an urgent change. And at that time, NFPA got rid of the entire chapter six, chapter six being the chapter for applicants. So at that time, April 2023, the medical requirements were the same for applicants and incumbents. You probably remember that applicants are category A and B. And let's say that we got some legal feedback that that was probably illegal, was enough legal feedback for the NFPA Senate's counsel to say, yeah, that's probably a good idea to get rid of that, understanding that, you know, to legal opinion, you might find another legal opinion out there. But I think at least to me, it did make some change. So after that change of April 2023, all the medical criteria are now in chapter nine, whether you're an incumbent or an applicant, they're the same. Also at that time, the NFPA staff decided to present all the medical criteria in the form of tables. So if you are used to the old document and now you use, I mean, the content's there, but the tables, let's say if you haven't seen these tables, it's definitely not intuitive. I already got involved in one legal case where, yeah, I guess I think I was reading the tables correctly because I actually wrote that piece. But the lawyers who retained me, they're reading the same table, they're reading something different. After a couple of back and forth, we were on the same place. But it's not obvious. And you see that you could have criteria for restrictions and criteria for no restrictions. So just be careful that you are actually reading what you think you are reading. Definitely it's new. You're not used to it. I'm going to spend a little bit of time reading it carefully. Again, we're still talking about what was decided in April 2023. The aerobic capacity requirement changed. And it changed to exactly what I'm telling you, 8 to 10 minutes to the discretion of the examining physician. And then you had essential chapter 15, which is the MS taskbook, really no big deal. But then to make things more interesting, in December 2023, NFPA came up with a new tentative interim amendment that was approved by the Standards Council. So that is the current official version. And that's the one I'm going to present to you. And I will tell you right up front, it's probably not the best standard you want to use. At least if you choose to use it, I'll be very careful. So that is not the paper copy that I have here. Dr. Haynes, I think you mentioned that NFPA has not printed that paper copy yet. But that's what you have on the website. And if you go to that website, nfpa.org, slash whatever standard you want, so 1582 for today, 1580 for the end of the lecture, you need to register with the website. It's free. So do it. And you can read the document for free. You can't print it. You can't download it. But at least you can read it. So that's the one you have today. So let's see what they came up back in December 2023. They decided that the METS, the aerobic capacity requirement would be different depending on age, sex and medical history. Any lawyer in the room? Can you have medical standards that are different for age, sex and medical history? ADA? What's that? Okay. So you see the age and sex. And I'm going to give you very specific examples. But then based on your medical history, so let's say you have a history of hypertension or your history of diabetes, now your METS requirement is higher than for other firefighters who don't have that medical history. Again, that is what NFPA says. So that's, I'm going to show you four tables of METS requirement. Again, that's what you have today in NFPA 1582. If you use a treadmill versus cycle ergometer, the numbers are different. That's not the issue. But if you don't have METS requirement based on your medical history, NFPA decided that you need to reach the 35th percentile of your population by age and gender. So if you're a young male, you need 12.4 METS. And if you are a 69-year-old woman, you need only to do 5.3 METS. Now if you are a 70-year-old male or female, I don't know if that means you have no METS requirement. Do you have a METS requirement? No. Okay. So again, that's the 35th percentile for people who have no medical history criteria. Now if you are in the category with coronary artery disease, hypertension, diabetes, COPD, pretty much any lung disease, now you need to meet the 50th percentile of your age and sex. Not a huge difference for the older people, but for the young ones, you get to 13.7 METS. Okay. So I'll give you a, I'm not a lawyer, we're not going to give you legal advice, but if you use the document, I highly recommend you get an employment lawyer before you use that. And if you have a client who insists on using the current version of NFPA 1582, it's probably a good idea for you to tell them, look, get an employment attorney because maybe that's an ADA violation. Again, no legal advice, but probably a good idea to run that. Now, on your end, if you think that doesn't make any sense because then the criteria are no longer job related, you know, again, that's up to you. You can tell your clients what you want. And I'll tell you what we think to do about it at AECOM. Okay. That's my favorite fight chief quite a few years ago here in Orlando. So let's see. He's in the 35th or the 50th percentile, probably the 50th percentile. So let's see. 60. Yeah, he can probably. Oh, you think he can get to eight or nine METs? Yeah? Okay. So that's where we stand today. For the future, NFPA is emerging, you see, four of their standards into a new standard called 1580. It's not a change in the content by itself, but it's a, what is that? You know, probably a hundred pages. Now you're looking at probably 300 pages, you know, probably will make it more difficult to handle. Also the technical committee in charge of that document is different. As far as the process for this document, we had the meeting for the second draft. The TIA of December 2023 for 1582 is incorporated into that new document. She is going to be posted in October. NFPA is always interested in public comments. If you have anything you want to say about that NFPA document, you know, you'll have a couple months. Now if going back to that original website, nfpa.org slash the number, the name of the standard, let's say 1580, you can put your email. So if there are any changes, you will get an email and including some of these. So if you want to be notified when the document is open for public comments, you know, you put your email because otherwise the window can be pretty narrow, you know, if you're not checking the document all the time. Or as I mentioned, you can join the public safety medicine section of ACOM and we'll probably tell you. But once you have these public comments, I guess, I don't know if they will have another meeting to review these comments, then you have that notice of intent to make a motion. So these are a much narrower type of comment. They don't always get that. And that one will close, I guess, at the end of October. And likely publication, I put 2025, could actually be earlier if there is no notice of intent to make a motion. Separately you might have used the 1500 standard. That one does not exist anymore. These three standards, 1500, 1521 and 1561 are now merged into 1550 and 1550 was published, the paper version was published a couple months ago. I'm going to show you two pictures and I'll tell you what ACOM plans to do. This is Dr. Gallet in Denver at ACOM. I think that's me on the other side. So at AOHC, we try to go to a fire academy, do a site visit. We had one yesterday at the Osceola Fire Academy. That's a lot of fun. We'll probably do it next year in Austin. It can be pretty exhausting. That was me in Orlando a few years ago pulling a charge hose. Dr. Haynes, that's an inch and three quarters, I think, a small one. That's extremely heavy. But that was a lot of fun. So let me tell you what we plan to do at ACOM. We don't think that these 1582 updates are viable for occupational physicians. Every single public comment was against these METs by age and gender. The vast majority of physicians who are members of the NFPA committee were also against them. So we're basically proposing an alternative to NFPA 1582, at least for the cardiovascular piece. The draft was created. We will go through exactly the same process as chapters in our public safety medicine guidelines. So we're finishing the draft internally, then it will go to the entire public safety medicine section, then the council for OEM science, then to the board. But the way we think of that is, if you need a stress test, whether it's for an aerobic capacity, well, let's say an artery, a cardiac re-stressification, or for a medical issue, i.e. return to work after an MI, just get a maximum effort stress test with imaging. And we won't care about the METs result, as long as the test is diagnostic. So obviously, if there is no effort, the firefighter is just walking slowly. You're not getting a usable, you're not getting a valid diagnostic test. But if you have a diagnostic test that doesn't show ischemia, we are done with our work. Separately, our expectation is that the aerobic capacity measurement, if any, this is something that the employer has to do. So the training division, management, they have to decide whether the person can or cannot do the job. We do the medical clearance. We are not telling the fire department whether that firefighter can climb five floors in the required amount of time, which, by the way, nobody knows that required amount of time. So hopefully, by next year, we'll be presenting the ACOM alternative to this NFPA standard that's based on age and sex, which may or may not be something you can use. Thanks. We'll get questions at the end. Oh, gee. Great. Wow. Look at all the people here. Pretty amazing. So you come to these conferences so that you — oh, Dan Samo, soon to be retired from Northwestern. I ran the OCMED there. Actually, they're throwing me out because my board's expired, but I was ready anyway, so don't feel bad for me. So anybody want — no, the job's already taken, so, you know. What? You can't hear me? Is that better? Okay. My mother always told me I mumble. So if I start mumbling again, just, you know, scream at me. So part of it is to educate you about public safety medicine, but I felt that I also had felt the responsibility to increase your worldview, too. So I'm going to introduce you to the Morton Botanical Garden, which is in Palm Springs, and it's this cool cactus place. So this is going to be cactus pictures. I'm going to push the buttons here. All right. So we're going to do some updates on our public safety medicine thing. And this — what we're going to — what's new or updated are the — I'm just going to tell you about the things that we're going to — that are in the works that are new or updated. And these are the things that we're going to — you're going to hear in this session or the next session. One is fibromyalgia. We'll be talking about that. Steve will be talking about stroke, an interesting topic. And cardiac valves, we have a — if we have time, we have a case presentation on that. Big updates, as Fabrice was mentioning, about the cardiac stuff. And we'll probably change our LEO guidance and our public safety guidance based on our new thinking about METs. Oh, please, also, everybody, don't use the word METS in front of Stanley. He anaphylacts. All right? You have no idea. Cool cacti, aren't they? So what are we working on? And we're constantly working on new things. We're constantly working on updating old things. This is going to be a life-beyond-my-lifetime project, which is good. So we have stroke, oncology. We're redoing all the cardiac stuff. We're doing sleep. We are going to do work on definitions. We have multiple sclerosis that we're working on. Renal failure is the piece we're starting on as far as renal. There's going to be a whole—I'll talk about it a little bit later—but a whole document, essentially, or a whole integration of EMS into our document, as well as correctional officers, dive teams, SWAT teams, and other public safety jobs. So eventually, we're hoping that our document will cover all public safety workers and will, within the document, tell you, you know, well, for firefighters it's this, for police it's this, if there is a difference. But for a lot of things, there is no difference. But we're working on that. So that's what we're working on. We have an all-new website. And for that, I want to thank my staff. First of all, AECOM staff. Audience applause. They have done so much to make last year an amazing success for the college, and especially for us. Isabel Montoya, who is going to be our leader and keep us organized and herd the cats, and Julie Orting, who is our super staff person. So I want to thank them. So go to the website. It's all new. Still little bumps and things. And if you see anything that's little bumps in it or things that are not working, please let us know. Let Isabel or Julie know, so that we can fix it. But this is a huge improvement over what we had before. And that has a lot to do with the improvements that have been made in the last year or two in all of AECOM's IT infrastructure. So it's really a lot better. Now, this is something that's coming up. The concept started when we were at a International Association of Fire Chiefs meeting. And the chiefs were saying, so, Dak, how do I know who in my neighborhood knows what the hell they're doing? Because I got this one guy sent me, and he just clearly didn't know what he was doing, and how do we know? So it started a thought process of, well, how can we do that? So what we're going to do, and hopefully that's coming relatively soon, and in bureaucratic terms, that's within the next century. So, what we're hoping to do is create a course. The course will contain 28 modules, 28 30-minute modules, so 14 hours of training, 18 of which will be required, and 10 of which will be elective. In other words, there'll be 18 you have to do, but then there's 20 others, and you can pick whatever 10 you want. Right now, most of it is planned to be online, so you'll be able to do it online. And so once you've done it, you'll get a certificate of completion. It's not a certificate of competence, it's not a board certification, it's just says you took the course. That information will be on a website, so that the chiefs, police chiefs, fire chiefs, you know, correctional officer chiefs, whatever it is, can go into the website and say, here's my zip code, 60657, how many docs within 5 miles, 10 miles, 50 miles, are on the list? Because if I'm going to pick someone to be my department physician, my agency's physician, they're probably going to pick it from this list. So at least they know that at least the person is aware of NFPA or ACOM's guidance or something, and then they have thought about it and talked about it. There will be some continuing education requirements, probably four modules a year. So, and probably like this course would qualify to, for all your continuing ed things, maybe it'll be done at component things, you could do it online. You know, we're still figuring out those little details. But we think that this will really help, you know, when you're listed. I mean, look, we all know that this is, you're here because you do that. You do this business, right? You take care of these people, and it'll be nice for your departments to know that you know what you're doing. So that's what's, excuse me. So actually, I'm real short. I'm 6'1", or at least I used to be 6'1", but. So that's all I have for right now. We're going to have Steve come up and talk to you about stroke, and he'll introduce himself, too. Okay. All right. Hey, my name's Steve Fisher. I work for the VA for the War-Related Injury and Illness Study Center. Is there anyone else from the RISC in the room here? Okay. So I know that retired Colonel John Barrett and retired Colonel Joe Ortiz are floating around here somewhere. So if anyone's interested in learning more about this consult service that's VA-wide, it's the War-Related Injury and Illness Study Center. So I came to the VA only six months ago. My prior job following 20 years with the Navy, working odd jobs, I had the good fortune of punching out of active duty right at the beginning of the pandemic when all sorts of folks were hiring. And I selected a fantastic place, the Smithsonian Institution. 8,000 employees across 23 museums and research centers, many of whom are very publicly facing jobs. So there was great need to have an on-site physician, fitness for duty, return to work. Of those 8,000 employees, I had about 1,000 security guards with guns guarding the national collections, people, places, and things, the National Zoo. They were federal law enforcement. So Fabrice asked me to write this chapter with him and share some of my experience. Let me do disclosures. I have nothing, no financial disclosures. Nothing here reflects the federal government, either VA or Smithsonian's positions. And I'm grateful to Dr. Sammo and Dr. Zarnecki. And I would direct you guys to the Public Safety Medicine website for a lot of good information. So perfunctory slide on two types of strokes, 90% ischemic, maybe 10% hemorrhagic, further classified according to anatomy. So we all have to remember our neuroanatomy to interact smartly with our consultants. This is a slide from the American Stroke Association, which is a branch of a shoot-off of the American Heart Association, just so that we remember, you know, hey, buddy, is that facial droop new? Is that you look a little bit clumsy in the hand dropping things or slurred speech? Time is brain. And if the Navy can teach 20 year old divers how to do a quick neurologic exam, or if we can, you know, teach Marines to do a quick neurocognitive assessment following a blast injury, you know, most of us, we just need to make sure that we're maintaining our skill set, you know, with, say, a five-part neuro exam, cranial nerves, motor strength in all extremities, somatosensory, cerebellar findings, deep tendon reflexes. So aspirational standards for the public safety officer. So, you know, we do vision screening, hearing screening. They should have the physical ability and agility to take somebody down, to address an assailant, to protect people and property. They should be able to, I pulled this out of our standards from Smithsonian, which were vetted and approved by Office of Personnel Management, which is just the standard we use for our federal organization, but be able to run, jump, kneel, bend, crawl, swim, you know, and some of them were, we, you know, we had a couple of them that were, you know, we had a couple of them that were, you know, we had reassigned a couple of people from the Chesapeake Bay area, you know, because we do small boat operations with security patrols for the Smithsonian Environmental Research Center. And actually here in Florida, there's a Smithsonian Marine Station that also has real estate off the coast of Honduras. So, yes, for certain operations, they have to be able to swim. And all of this should be spelled out in their position description or as essential tasks. Okay, next slide. So I have to cover EPI, and so pulled right out of CDC, I'm going to talk about EC. One in six deaths from cardiovascular disease is due to stroke. About 800,000 people in the U.S. have a stroke. For over 600,000, it's their first or new stroke. Cost to society, over $56 billion. That's 2019 data. And it is a leading cause, not the leading cause, but a leading cause of long-term disability. I wanted to, oh boy, this didn't format well. Let's see here. So I wanted to go over this slide a little bit. Again, pulled right out of CDC's website on stroke, but it's important to know your population. You know, if stroke is the second leading cause of death and leading cause of disability, let's say where I am in Washington, D.C. area, you know, it's kind of, if I can depart here, I can project. Let's see. I mean, it's, this whole area is very, you know, dense with 89 to 178, you know, cases per 100,000. So, you know, if I've got a battalion of 1,000 guys with guns and women, it's not surprising that I had a few strokes every year. Particularly, you know, when I sat down and went over the age structure of my population, I was, you know, at 50-ish, I was young for Smithsonian. We've got an overworked face, from early 20s to security guards in their 70s, and most of whom were over the age of 50. So in my three and a half years throughout the pandemic at Smithsonian, I had to deal with a few strokes per year, you know. For the Washington, D.C. across our museums and research centers there, a lot of our population is African-American. This area throughout here is historically called the Black Belt. A sociologist named W.E. Du Bois, he's a Haitian ancestry, he insisted on pronouncing his surname with a cast voice. In 1896, following Reconstruction, he was hired to compose a landmark study called the Philadelphia Negro, because so many folks from the Antebellum South, post Reconstruction, had migrated north. In 1899, that study, the Philadelphia Negro, was known as a classic in social epidemiology. A hundred years later, Nancy Krieger, another epidemiologist at Harvard, published studies on the great migration patterns, and people in the second, third, fourth generation that moved to northern cities, if your ancestry is in the Jim Crow South, you carry with you a lot of the mortality similar to the Black Belt, so folks from Chicago, New York, Philadelphia. That's Nancy Krieger, an epidemiologist at Harvard, who draws a lot on W.E. Du Bois' demography. Now, I can't explain, you know, the great migration patterns that are common denominators with mostly white communities in Appalachia. You know, when I look at these CDC maps on whether it's stroke, tobacco use, hypertension, cardiovascular disease of whatever nature, obesity, it seems this region, Appalachia, some of these rural farming areas in between urban populations and Indian reservations out west and up north, you know, the common denominators seem to be poverty, poor health literacy, inaccess to health care, and that was a big issue for, you know, these are social determinants of health. These are big issues for my population in the Washington, D.C. area, okay? So I just wanted to take a microsecond to appreciate the geographic medicine, you know, what, you know, this group, we still care about geographic medicine. Some of those departments turned into preventive medicine, and then they went away altogether, but it's coming back. So further identifying population at risk, we talked a bit about understanding the age structure of our population and the prevalence. We're, you know, we're not going to necessarily, you know, it's not, it may not be legal to deny somebody employment up front, you know, requiring an echo for a PFO, but if they had a stroke or a TIA, you know, you definitely want to think about, you know, PFO or stroke due to carotid artery dissection. So you're going to want to look at imaging from, you know, the echocardiogram, Doppler's of the neck, you know, workup for cryptogenic stroke, undiagnosed AFib, one in seven strokes, and are caused by, thought to be caused by AFib. And if they did have a PFO, you would want to further evaluate their recovery. You know, AFib, you know, if you mess with the myocardium fixing an atrial septal defect, you know, you can trigger a dysrhythmia. So AFib is the most common complication post PFO closure. So questions that we would have clinically is, you know, one, what is their risk of recurrent stroke? And two, their risk of post-stroke seizure. So in subsequent slides, we're going to focus on that. All right. Other risk factors, hypertension, hyperlipidemia, diabetes, et cetera, morbid obesity, very common, sleep apnea, very common in my population, tobacco abuse, stimulant abuse, meth, cocaine, AVMs infection during the pandemic, COVID has a tropism for the cardiovascular, you know, are they on it? You know, we had a number of people on anticoagulants, mostly Eloquist, you know, the risk of a bleed on Coumadin. I had one case where I had to follow up a guy every month to make sure he was compliant with Coumadin Clinic. So these are all considerations. And, you know, we can mitigate some of these risks with through having engaged employee health. I think some of the occupational health nurses from Smithsonian are here. They run very robust engagement in employee health, providing anticipatory guidance, educational counseling to help address health literacy and compliance on medication. And it's cost effective, in my opinion. Okay. Getting through the slides. So one of my side jobs, I moonlight at critical access community hospitals in rural Louisiana. And a wonderful thing that I've seen in the last 10 years are a lot of these small hospitals have telestroke relationships with centers that have a stroke team. And, you know, so some people get to a multidisciplinary team with neurocritical care consult. Others don't. And, you know, some people get to a multidisciplinary team with neurocritical care consult, others don't. And so some of my clients that may not have had the best care to evaluate whatever happened to them, they may not get a metabolic workup, TSH, COAG studies. They may not have had a halter looking for dysrhythmia or say an EEG with and without sleep deprivation. So when I demand or ask for some of these studies, I get negative feedback from the law enforcement officer saying, hey, look, this is costly to me to have to go back and say this is required for my work. But that's in the best interest of workplace safety in my opinion. Okay, I just put in vision screening again. Often in the position description, there's a requirement to maintain a driver's license. And so we have a separate section on vision screening standards, but they also have to meet the vision screening standards for the driver's license. Okay, so again, when you're seeing them after they've seen, once you find out that they've seen their healthcare provider, you're gonna wanna assess the motor function and assess the degree of impairment, document sensory cerebellar signs, et cetera. And if we can keep them on the job in some fashion through a workplace accommodation, whether working desk duties for a year of observation or in a control room where they're with other people monitoring screens in a panopticon, we do. So those are considerations. The risk of post-stroke seizure falls to 1% after a year. So often, it's reasonable to have light duty, limited duty, non-weapon bearing duty, or not patrolling alone. Not a good idea to have them night shift going up and down stairs to the tops of buildings in that first year. That's my advice. We can use the CHADS-VASC score to calculate risk of stroke in the setting of AFib. I don't know if you guys use MD-Calc, but all of these scores can be found on MD-Calc. So for CHADS-VASC, you'd plug in age, sex, CHF history, et cetera, and you would get a risk number. So again, it depends on how risk-averse your organization is. 1% or less of, you know, I would tolerate. If there's, you know, if they have a PFO, you would calculate a ROPE score, the risk of paradoxical embolism. And again, that can be found on MD-Calc. I recommend to stratify risk. Okay, so TIA versus stroke. This is something that we anguished over last year in the Public Safety Medicine Working Group. For, you know, years on out after a TIA, you know, people remain at about 5% likely to have a stroke after TIA. So do you keep them on the job, or do you put them in a light limited duty status? So again, similar workup to assess risk. So, okay, the next, so the next couple of slides are actually drawn from the Federal Motor Carrier Safety Administration's expert working group from 2015 on this topic, you know, risk of stroke following TIA. So six months out, and one year out, two years out. So similar numbers. So in researching this, I drew a lot of information from the Federal Motor Carrier Safety Administration to see how they do it for commercial drivers. I looked at the FAA guidance. I looked at military policy. You know, I see some Navy uniforms in the room, Naval Aerospace Medical Institute. Henry Porter was a neurology consultant for NAMI who wrote policy for return to flight duty after stroke, and Joseph Connelly is the master neurologist for USAFSAM, for any Air Force bubba's in the room, who actually presented on this same topic two weeks ago in Chicago. But this is the data. This is, you know, this is what we have, you know. So you'll have to evaluate, you know, your employee and decide if, you know, if they got lucky and it's, you know, it's an accident that's neurologically silent, or if they can be adapted to their work environment safely, you know, versus medical retirement. I had to deal with a lot of EO cases on, you know, restricting people to certain work hours where they can be in a space with others. You know, Dr. Fisher is limiting my ability to earn an income because they can't work an overnight shift alone, but it's in the interest of workplace safety, and we just kinda stuck to our policy. Are we gonna open up to questions? Have I had 20 minutes yet, or am I over 20 minutes? I'm way over 20 minutes, aren't I? Yeah, but we're good with time because we didn't do long introductions, right? All right, so, you know, are there questions regarding, Sabin, are we? Okay. Yeah, thank you. Thank you, Steve. Thank you. One other thing is that we do have a public safety list server, so if anybody wants to get on it, Stanley, will you stand up? Remember, do not use the word Mets around him, unless you have an EpiPen with you. But you can give him your card with your name, your phone, and your email address, or write it on a piece of paper. He'll have a little yellow pad if you don't have paper. You can use paper towels, toilet paper, whatever you want. Stanley takes everything. Okay. So the next thing we want to do is a little case presentation. More cacti, by the way. We're keeping that theme for the whole hour. And this was a 39-year-old police officer who had a congenital bicuspid aortic valve. And he became a police officer in 2008. He was seen for his pre-placement evaluation, and he was cleared to go to work. And he did fine. He finally went in 2011 for routine follow-up, which is supposed to be done 10 years after he was diagnosed, which would have been in, you know, 1980 or something. And it found that he had aortic regurge, left ventricular and aortic root dilatation. And long story short, it was recommended to have valve replacement, which he had done. They put in a mechanical valve. He was anticoagulated. After his surgery, he was in complete third-degree heart block. And he was given a permanent pacemaker, and not on demand, but, you know, he was pacemaker-dependent. He was released by his surgeon after six weeks and went back to work. Remember when I talked about that the chiefs want to know, can he come back to work? Does that person know what they're doing? This guy was returned to work. A year later, he was in an altercation with somebody, and he suddenly got short of breath and cyanotic, and workup showed that he had developed cardiomyopathy, and he never did return to work. This is my favorite cactus, by the way. You all know this cactus? It's the agave cactus. It is the source of tequila and mezcal. Favorite cactus of all time. So we're going to talk about this a little bit, and if anybody wants to get up and scream loud enough for everybody to hear you is what do you think about his management, let's say, you know, following his surgery? And we'll all speak at once, because otherwise, Fabrice is going to start talking. Eduarte? So the question that comes to my mind is... Maybe you want to come to the microphone. Yeah, you do, because, you know, they yelled at me for mumbling. What about you? On behalf of the section, thank you for a fantastic turnout. So Danny, question to you, or the group is, was this a coincidence that he developed cardiomyopathy one year out after having an uneventful valve replacement? He developed cardiomyopathy. He still had some, probably because of the prior, the valve was leaking and it was a jet hitting into his heart. So he continued to have aortic insufficiency. He developed a dilated... He did still continue to have some aortic insufficiency, yes. So look, here's the guy. After surgery, he has a mechanical valve. He's anti-coagulated. He's a police officer. And he has a permanent patient. That's not fair. You didn't give me this information before I got up here and acting like an idiot, because look, there's an awful lot of more information here. What are the things here that are bad? What are the things... I mean, the valve, and we're working on a whole chapter on valves and all that stuff. The valve itself is good. That's fine. If it works and it's doing well and everything's great, that's great. Number two. Fabrice? He's anti-coagulated. Take the mic. So he's anti-coagulated and they put a pacer in. And can he do 12 meds? That was a joke. See, Stanley has a rash. Daniel. So what... You're going to talk about the anti-coagulated part? Can we see the report of the echo? Like the numbers. No. We don't have that. But look, anti-coagulated, and that's in the medication chapter. That's one of Fabrice's babies, is that we know that police officers are going to involve probably in altercations and are likely to hit their heads even with minor head trauma. The risk of having a bleed is high. So anybody who is permanently or fully anti-coagulated, even people say, well, I'm only partially anti-coagulated, which is kind of like being slightly pregnant. If you're anti-coagulated, you're at risk. That does not include aspirin. That does not include platelet. That's when you're anti-coagulated. So A, when he was evaluated after a surgery, just that should not have gone back to work. Then he's on a permanent pacemaker. He's pacemaker-dependent. Yeah. So what we found out is if you fight with people or if you shoot a rifle or a shotgun, that's enough to break a lead of a pacemaker. So you can have a pacemaker if you're not pacemaker-dependent, but if you're pacemaker-dependent and your pacemaker fails, you become suddenly incapacitated. That is unacceptable. So there's another reason he should not have been released to work. All right? Okay. What if he gets tased? I'm sorry, what? What if he gets tased? What if he gets tased? Yeah, that would not be good. But the idea is he's supposed to be tasing others. Try not to tase. But you're right. No. And one of the things we have is when you're using different pepper spray and stuff, you're going to get it yourself. And of course, cops, because they're all macho, when they're training with tasers, they have to be tased. I don't know. Because you shoot a gun, do you have to be shot? Danny, Danny, you have three questions. Okay. Hi. So with your anticoagulation, does that also include Xarelto or some of these newer ones that you don't have to monitor? So is that also anticoagulated to the point where you say you would not return that person to work? Yes. Okay. So anti-platelets are fine, but not anticoagulants. And yes, the novel anticoagulants are also a problem. So that... Oh, Danny. Oh, I'm sorry. Hi. Question regarding pacemaker dependency. Will you be defining pacemaker dependency in the addition that you talk about CBAs? About... Pacemaker dependency, they're kind of different definitions, but will there be a standard definition like in the LEO guidelines? I think that's... In terms of the beats? I mean, a lot of people have pacemaker because they have something that, you know, they might need it at some time, or it's not needed anymore. And we do talk about that. I mean, it's in the chapter. So if you have a pacemaker and you don't need it anymore, but it's, you know, they're not going to take it out, you're fine. But if your pacemaker is firing all the time and it's being used all the time, that's pacemaker dependent. If you have a malfunction, you become suddenly incapacitated or dead, which is kind of like suddenly incapacitated. Yeah. Yeah. Because sometimes, like in the cardiology literature, I don't know if there's really a consensus to what exactly is pacemaker dependency. But a lot of times the number I see, is it 30 if there are less than 30 beats per minute? I don't know. We need time here. Yeah. Yeah. Our cardiology guru who's writing these chapters couldn't be here because he said it wasn't worth a divorce because his daughter was this and the family that, and God knows what. So that's a good question. We do need to put them. We need that in there. So the next thing is, so that we all agree that he should not have been returned to work after a surgery. So in a year, he did fine for a year until he was involved in the altercation. And then he became, he suddenly became decompensated. And then, but of course, what are they saying? Would you send him back to work now? Nope. Wouldn't send him back to work first time, but certainly after the second time, no. He had developed cardiomyopathy and he clearly was not fit for duty anymore. Here's the big question. Ah, see, now this is where, you know, the rubber hits the road. I got the answer. I got the answer, NMJ. So NMJ is one of SAMA's rules of dealing with bureaucracy. It stands for not my job. This is not a medical question. It's not, but they're going to say, well, no, here's the argument. He was doing okay for a year and then because of the alteration, altercation, his condition got worse and now he can't do it anymore. That's what his lawyer is going to say. And you may have to say, oh, come on, that's bullshit. I see you're all familiar with that medical term. So okay. So that's the case presentation, but we do have time for some questions. I think we have time for some questions. I think you ran out of time. I ran out of time? Yeah. Maybe we'll do the question at the end. Okay. We'll try and save some time at the end of the next session. And don't forget, if you want to get an enlist serve, bother Stanley. If you're staying, we'll do questions at the end of the next session.

Fabrice Czernecki

police officer

prosthetic heart valve

complications

congenital bicuspid aortic valve

valve replacement surgery

pacemaker implantation

cardiomyopathy

fitness for duty