A little bit about myself, I've been a medical officer with NIOSH for 20 years this July, so I can't believe it's been that long. I started out in the Health Hazard Evaluation Program, and in 2020 I moved to our Firefighter Fatality Investigation and Prevention Program Medical Team. That's quite a mouthful. So one of the other hats I also wear is I run our Resident Rotation Program, and at the end of the presentation I'll put out some information on that. So let's get started. It's on here. Let's see. Is that better? All right. So I should be holding it here. So I want to go over on this talk a little bit about atherosclerotic cardiovascular disease in the U.S. Fire Service, as well as the risk factors they have in common with the general population, and some that are actually really unique to those in the Fire Service. And then we'll go through some risk reduction strategies. So a little bit of background of some of the relevant agencies, because that was one of the first things that I had to get sorted out when I first came into the Fatality Investigation Program, is who does what and how. The U.S. Fire Administration is part of Department of Homeland Security's Federal Emergency Management Agency, or FEMA. And they have many different services, one of which is a voluntary collection service of firefighter fatality notices. So when there is a death in the department, there's no mandatory reporting requirement for this. But the departments can voluntarily submit the fatality details. And anyone can go on the FEMA website and be added to this distribution list. And they send out notification emails to everyone on that distribution list that gives a little description about what happened, point of contact at the fire department, and where any memorial attributes are being held. So that is our primary way of also how we find our cases. So they also do a lot of statistics based on the voluntary reporting data that they get. And according to their statistics, and as of April of 24, we had a little over a million firefighters in the United States, staffing about 27,000 fire departments. The majority are volunteers, followed by career and then some paid on-call firefighters. And this includes both structural and wildland. The other major player in the U.S. Fire Service is the National Fire Protection Association, the NFPA. So most people are familiar with OSHA's respiratory standard, respiratory protection standard. And that is one of the few areas that OSHA directly oversees the U.S. Fire Service, specifically in the area of their SCBA gear, as well as other specific situations such as confined space entry. But other than that, the standards that firefighters hope to achieve are those that are set forth by the NFPA. And the important thing to remember about the NFPA standards are these are consensus standards. These are what the relevant body thinks are the ideal way to screen or handle or approach any situation involving the fire service. So they're not enforceable, but they are recommendations, and they're what we always cite to and refer to in our fatality investigation reports as their basic guidance. They were actually around for a pretty long time. And as you can see here, they started out number one, and the standards that we use for the fire service are primarily standards 1581, 82, 83, and 84. And for those who attended Dr. Czarnecki's presentation yesterday, you'll have heard the news that there is currently an effort in progress to consolidate all those four standards into one single one, 1580, that is expected to come out in 2025. So the simple question of how many firefighters are having fatal heart attacks is not such a straightforward question when you try to go and look at the data, because it really depends on where you get your data from. So again, these are voluntary reporting for the NFPA, sorry, for the U.S. Fire Administration. And according to them, they use the definition of a line-of-duty death as derived from the Public Safety Officer Benefits Program. And this is the program that when there is a line-of-duty death, this is the program that gives benefits, monetary benefits, to the spouse and surviving family to help support them after the loss of their loved one. Originally, when this came out in 1976, it only covered traumatic deaths. But in 2003, the Hometown Heroes Survivors Benefit Act included heart attacks and strokes as line-of-duty deaths, not only if it actually happened while they were working, but this also, you see the caveat here, for also those that occur within 24 hours of finishing a shift. And you'll see a little later on that that creates some interesting challenges when looking at the data, because prior to 2003, they wouldn't be included in the reporting data at all. And by having that extension of the criteria period of that 24 hours after last duty shift is really important, because, you know, sometimes that heart attack doesn't happen right away, but all the exertion that they do on scene may catch up with them after they get home. So this was a way to make sure that, in those circumstances, the firefighter family would have some benefits. And when it came out in 1974, our regime was 50,000, and it's gone up to about 200,000 or so. And this is one of the immediate tasks that the spouse and the family have to take care of in the immediate aftermath, to make sure they file within deadline periods to get these really important benefits. So with the NFPA, they, up until two years ago, defined heart attacks as a line-of-duty death only if the symptoms started while they're actually on duty. So you can see here where we start having some of this conflict, where the USFA includes the heart attack within 24 hours of finishing your shift as a line-of-duty death, where the NFPA does not. And it just gets snowballs from there, is the difficulty of sort of teasing out your data, what's actually being covered and reported. They did actually expand this definition to be consistent with the USFA last year. So hopefully that will make things a little easier, doing some data mining going forward. But what we can look at from the data that we do have is, not surprisingly, we see from the USFA database that volunteers have many more line-of-duty deaths than career firefighters. And just so you know, this presentation, the slides are in the app, so you can reference them there as well. Now USFA also includes, in the category of heart attack, as well as the myocardial infarction itself, also death from adenarythmia. So it's like, all right, here's another challenge to actually say who actually had a heart attack versus those that had other arrhythmias, leading to the death that they are now calling a heart attack, which actually may not have been a heart attack. So it becomes challenging. One of the other things that we saw here, again, was that the deaths seem to increase by age, both in the career and volunteer firefighters. And here is a list of some of the activities that these firefighters are doing when they had their fatal event. About 40% were those that weren't actually on scene when it happened. But you can see, pretty much any aspect of the fire response, it's pretty much happened. So there's no so-called safe area. Unfortunately, with the USFA database, up to that time, they separated out the hometown heroes fatalities. Those happened within 24 hours of finishing the shift versus while they're actually on shift. And you can see here, it parsed out by age, just for those that actually had their heart attack on shift, that it peaks out in the 50s to 60s. The NFPA statistics also are consistent, showing more line-of-duty deaths in volunteers than career firefighters. This becomes a recurrent theme as you pretty much approach any subject with the US Fire Service. Because even the large municipal departments that have really great funding are finding challenges as far as keeping up training, providing services and facilities. Because oftentimes, when there's a need for an upgrade that involves a cost expenditure, and where does that cost come from? Often from tax levies and things like that, that get voted on if people don't want to pay more taxes, then that extra funding source doesn't come in. And if municipal departments and well-funded city ones are having trouble getting funding, imagine what it's like for these volunteer departments, these small ones in the middle of nowhere. They're on a shoestring to start with, and it becomes very challenging for them to provide that same level of care, if even approaching it, than what you see at paid departments. So that's always been an area of focus on, and how can we help these departments more? And actually, the IAFF worked jointly with the National Volunteer Fire Council on creating a sort of side-by-side standard, which specifically aimed towards volunteer departments, giving them tips on how they can utilize other resources to try to approach the NFPA standards with the minimum resources that they have, such as if you're looking to annual medical exams, you don't have the funding to contract out yourself or hire your own fire department physician, they encourage people to reach out to local hospitals or internal medicine practices and family practices to see, you know, look, would you be willing to help us out as a fire department, your local fire department, to help us take care of our firefighters? So that document has a lot of good resource information for volunteer departments. So going into some general CVD risk factors, we all know these, the non-modifiable and modifiable risk factors here, and these come from the CDC website. The American Heart Association actually has some additional ones that they put up, and you can see them here. And as you can see at the bottom of this, we have stress, and stress is a huge thing. I think most people don't realize what goes through and what sort of daily, day-to-day worries that your firefighters are carrying with them. And this cartoon, per se, is a really nice depiction of how they seem to be getting concerns from all sides, from the fact that, you know, they're exhausted, they're often doing 24-hour shifts back-to-back-to-back, they may need to get called in to do overtime because of short staffing at a department, so they feel they have to stay on even longer. Then there's always concern about their welfare, especially with about a study rate of around 100 line-of-duty deaths per year, you know, will I come home tonight? Will this be the last time I see my family? And then the cost thing comes up here on the side here. How much are these guys worth? According to the National Labor Statistics, firefighters make about $50,000 a year for all that they do. So there are all these financial stressors as well. So you can see that while it may not appear to be a huge issue, it really is with them because pretty much every aspect of their life is impacted by some amount of stress related to the job. And certainly their inadequate sleep, oftentimes if they're in the busy department, combined with irregular schedules, make that even more problematic. Not too surprisingly, firefighting is a high cardiac demand job. They are doing a lot with a lot of gear on and what they have to carry. The basic gear here, and I'll have a couple slides coming up to break it down a little bit, adds about 50 to pounds, 50 to 60, up to 70, maybe, depending on the size of how big your air tank is. So imagine pulling that with you on everything you have to do. And on top of that, if they need to get equipment somewhere, like as you can see here up on our roof, they've got to then carry all that stuff with them in addition to what their protective gear that they're already wearing up to that roof and then use it. So sometimes some of these chainsaws can be around 25 pounds or so. So just imagine if you had to walk around doing your basic job test carrying, what, 75 extra pounds at least all the time. And that may include people as well. So whether you're carrying them down a ladder or getting them out on a ground level of a house, that's still a lot of work. And if you ever go to a fire academy training session, you'll see like dummy drags are a basic staple of some of their training tests that they have to do. And this is also relevant to wildland firefighters, because even though they're in a separate situation, they have the same challenges of whatever gear they're going to need, they have to take with them. And when you're a wildland firefighter, you're in a remote area, that becomes even more of a challenge. So here's a take a look at some of the basic gear that structural firefighters may be using. So the basic setup is in the middle, the irons are on the left, and then the roof is on the right. You'll see the hook that the gentleman is holding there, that's a ventilation hook. That's used to tear into a roof and open it up to ventilate smoke out of the house. Some of these hooks, like this one may be 20 pounds, they have really big ones that require two people to handle them, and they're about 80 pounds apiece. So these ventilation hooks can get really big really fast. And here's some pictures from wildland firefighters. These are photos that we took in 2014 when I went out with them in Northern California to the French fire that it was called. We tied in with a whole bunch of crews, ranging from those just out of high school to those that have been in it for a whole lifetime. You see here this gentleman holding the saw on his back, he's a sawyer from Anchorage, and that chainsaw, that blade alone is four feet, and he has to carry that with him on a shoulder pad. The ones you see on the right are what's called the elite of the wildland firefighters, called smoke jumpers, and again, wildland firefighters fight fires in really remote areas, and sometimes the only way to get to the fire is by air, because there is no road. And they run into the same challenge, well, they still have to take gear with them, and you can see the components of his gear on that top right picture, but whatever he packs in, he's got to hike out to the nearest road where they can tie into a ground vehicle to come back. And in fact, with wildland crews, their pack tests are having to carry 110 pounds three miles in 90 minutes or less. So just imagine that as your basic work requirement. Hose lines, these are a staple of your structural firefighters. They come in all different sizes, and even the weight of an empty hose line is considerable. And you can see the different size of the diameter hose lines and what they weigh, both by itself and when it's called charged. I mean, once it's hooked up and they open up the hydrant and it runs through full of water, that's called a charged hose line. And it's not just the weight of the water itself added to the pipe, because these hose lines get water supplied from very high pressure sources. There's actually rules that usually it's two people manning a hose. One, the front guy, he's the nozzle operator, and his job is to aim it. The guy behind him is to help brace himself against the force of the hose that wants to kind of run amok all over the place under the whole pressure. I'm sure most of you, if you've turned on a garden hose that you didn't have a hold of at the end, it kind of snaps and flies around uncontrollably. Well, that guy in the back, his job is to hold that thing down so the nozzle operator can have a chance of actually aiming it where it needs to go. So they're not just sitting down on the ground. They are exerting active force to hold that line in place while it gets aimed at the fire. Heat stress, this is always a big one. You get a lot of contributing factors to their net heat load, whether it's the ambient environmental conditions that you see on the top page. From Arizona, they're up in the cherry picker in full turnaround gear at 106 degrees external temperature, and that's just starting your work. You also have the heat generated by your exertion, which often gets underestimated, especially if you're in a relatively cool environment. People sometimes have difficulty imagining how you can have heat stroke if it's like 70 degrees outside. It's because of this heat generated by exertion. And then you have the heat from the fire itself. And just to give you an idea, standard house fires can burn up to 1,500 degrees Fahrenheit, and so you don't even have to be anywhere near that house to feel the heat radiating off of it. And depending on how big the fire is, and if you have a multi-alarm fire where you're on site for sometimes hours putting out that fire, that's a huge heat exposure, which is exacerbated by the fact that their turnout gear is wonderful at trapping that heat. So you can't get any sort of convective or evaporative heat loss at all. Now, these are some less obvious risk factors that are unique to firefighters. This is their dispatch system. And has anyone ever worked as an EMT or a volunteer firefighter? Anyone? Then you'll know what I'm talking about here. I was an EMT with a rescue squad before medical school and all the way up into my third year of clinicals when I couldn't keep up the call schedule anymore. And there is no more jarring way of being woken up out of sleep than your dispatch. So I thought I might give you a taste of what that's like. If you could close your eyes, think of dinner or activities you're doing or just relaxing, and then all of a sudden you're talking to a friend and you hear this. Response time to that location. I've created the APS. There we go. This is what they were working on. Oh, my goodness. I guess they're not working. I was so happy when they got it set up for me. Let me see if I can just do it by hand. Because it's one of those things you have to experience to truly appreciate how horrible it is. Feeling alive, not the congestion. Live Claritin Clear. All right. Now this should go. This system is integrated with dispatch so that you can provide the optimum response time to that location. I've created the APS Firehouse Alerting System to provide a more safe environment for the firefighters responding to the scene. Once an alert goes out, we have the system go from a non-emergency function to an emergency function. In our bunk rooms, when we get alerted for a call in the middle of the night, we use soft LED lighting and volume controls that come up gradually as not to startle somebody when they wake from a sound sleep. It has been studied about the health issues when you're startled awake at night. APS has put systems in place that give us the proper lighting in order to safely get out of the bunk area, get down to the business of delivering emergency service. The tones are also specific to either fire or ambulance. We have the ability to lock out either EMS or fire so that when we do get a call, that we can respond refreshed and ready to go. I'm sorry. I thought I had that working again. Put your rope on the door. All right. Well, that was a fail. Sorry. They practiced it when I was up here earlier. Basically, each station has a dispatch tone, and when that tone comes across your system, the volume gets amped up so that everyone is on alert before then the details of the dispatch, like which engine, which company is being called out, what type of call it is, it's usually a chief complaint, and then they go out. But the problem is every time this happens, you can imagine the startle reflex that happens, especially if you just finished lots of calls, you're trying to get some sleep, and you finally manage to fall asleep when all of a sudden floodlights in your bunk room go on and the volume ramps up through the whole building of your tones followed by dispatch. Oftentimes people will just—or at least I know our group did. It was much kinder to try to stay awake all night than try to go to sleep and get woken up like that. SHIFTwork itself has a long research history of showing its impact on everything from your blood pressure to obesity, triglycerides, and cholesterol. And imagine that also so happens to be many of your major cardiovascular risk factors. So with firefighting, a lot of these risk factors tend to play into each other very much like this. There we go. So I don't want to—I'm not going to go into this graphic, but I put this in there because this is done by Dr. Stefanos and Cal—sorry, Dr. Cales and Dr. Smith in 2017. And it's a really nice graphic of all these different risk factors that sort of play in and off of each other to make cardiovascular disease a really common thing with the fire service. Nutrition is a big thing. Well, when you're working any type of on-call job, you're pretty much guaranteed to have a regular anything schedule, whether in a regular sleep schedule, a regular eating schedule. It's a matter of getting that food in while you can before your tones go off. And oftentimes, I remember on my call nights, it was more like as soon as you got your food, you shovel it in as fast as you can because you never knew when those tones were going off and you'd have to drop everything and sometimes not get back to the station for three hours later. So you have a regular meal schedule, inconsistent healthy cooking. There's been much greater emphasis these days on improving what gets served by the crews to each other. And you may have heard very much that firefighting is like a big family, and especially the guys who bunk and live and work out of the same station, they consider mealtimes a bonding experience. Everyone takes turns at preparing the meals. It's often done family style like you see here, and that often comes hand-in-hand with issues of portion control. And last but certainly not least are gifts from the community. These gifts are often the form of things that people like and crave, not necessarily healthy things, such as this dozen, 12 dozen donuts that go to the fire department from a local bakery or when the local community gives them home-baked goods. You don't want to seem ungrateful and you want to show them you really like what they brought by eating it. And then, well, let's say you've gone through about a dozen of these donuts and the rest of them are sitting out in your call room, and well, you know, it's quick and easy and you wind up going through all 12 dozen before you know it. Smoking and tobacco use is a perennial issue with not only the fire service but other first responders as well. And as you can see here, it's going down, it's getting better. The firefighters are depicted on the graph as the blue triangles. So we're around at 5%, but, you know, as you all know, we would like this to be a big zero. Going back to stress factors in firefighters, there's a lot of contributing factors here. Primarily is you have firsthand involvement in very emotionally draining situations. At the very best, if there's an actual fire when you arrive at a scene, there's going to be damage. A business or a home has incurred some damage that will require a financial burden to repair. If they're lucky, and if not, everything's burned to the ground. So now you have a victim or a business who have lost everything in a matter of minutes. And it's a hard thing to deal with when, like, no matter sometimes how hard you try and all the efforts that your crew puts in, you can't save the building. Even worse, if there are actually victims inside the building, if there's a fatality inside, you know, could you have gotten there sooner? Could you have gotten or done more to get them out? And that is something that goes through the mind of a firefighter every single call. Then you have, obviously, their spouse and family concerned. You know, when dad goes off to work, will he come home? Especially whenever there's a line of duty death, it's all over the local news. And it just brings these issues up again and again. Shift work, taking time from spouse and family, is always a big one. You know, when mom and dad are in a banking job, a regular merchant job, and they're working, like, the 9 to 5 schedule, they're always available to be there for the kids or each other at night or on weekends. That's not the case with a firefighter. They are on schedule 24-7 at some point. They can be very hard to link up with family for family events and find themselves missing out on things, as well as just not being there as a regular presence for their spouse or their kids. And certainly concerns for the family welfare, you know, the public safety officer benefits are a one-time thing. What will happen to them afterwards? Who will take care of them? How will they do? Will the kids be able to afford school? Everything. Those concerns are always in the back of their head. And certainly any other line-of-duty deaths that occur, especially if it's in your own department or neighboring departments, it is like a very close family, especially over localized geographic regions. And it hits them hard every single time that there's another death because you're always thinking, you know, they're but the grace of God to me. Could I be the next one that they announce? So imagine carrying that with you every single day of your working career. These structures may result in self-medication, whether it's with food, alcohol, illicit substances, other addictive behaviors like gambling, anything to get those worries off your mind just for a little bit. And there's certainly, it's getting better, but there's certainly been a stigma in obtaining mental health assistance. Some of the investigations that I did when you talked to the departments, the crewmates of the deceased firefighter, and I remember asking a couple of them about, well, do you have EAP programs? Do you use it? And I found that there's a huge misperception of what EAP is there for. They expect when they call EAP to get someone who can actually understand what their issues are and help them throw it. Not really many of them understand that it's basically a referral service. So they'll set them up with someone who can help. And when you have a couple of firefighters who try to call EAP and they find out, oh, he just told me to call someone else. They're no use. And then they start, that word gets around and they start not using it. So you have underutilization of that resource. But it's really good to know that most departments, especially larger ones, have really good peer counseling networks. And many of the investigations that I've done, that's been a huge help to the coworkers and the family, just to know that there is a support structure in place if the worst should happen. And as a very unfortunate example, many of you may recognize this photo. This is Captain Fields carrying the lifeless body of a baby out of the rubble from the Oklahoma City bombings. And that happened in 1995. Captain Fields retired in 2017. And he said in an interview that even to that day, despite having a lot of counseling and help from all areas, that there's not a day that goes by that he doesn't think of this little girl. So as occupational medicine physicians, when would you encounter firefighters? There are three types of medical exams that you may be involved with. The first one at the beginning of career when they get their medical screening exams as part of their firefighter academy applications. Then if they get in and they're an active firefighter, the annual medical evaluation and any return to duty assessments. And this is sort of where the idea of doing this talk came about. Because although many departments have their own what's called fire department physician or a contract with an outside service like concentra to do these type of exams, many volunteer departments do not. Or there are individual visits that people go to that may not be really active in dealing with or working with firefighters. But at the same time, you really have to know what your patient is doing or what they may be doing in order to truly be able to sign off that they are good to go for this very demanding job. And I found this little piece on one of the one state's return to work form for the physician. That they actually had to sign off that they reviewed the employee's job description and their work schedule. And knowing that, were able to clear them for duty. And I think there's also an idea that people kind of know nebulously what firefighters do. I mean, even if you ask a first grader, what does a firefighter do? Well, you know, he puts out fires and gets the cats down from the tree. But it is so much more than that. And that takes us back to NFPA again. This standard 1582 has a very detailed list of what the essential job tasks are. And I put a few of the examples here. And they are very specific, as you can see. So it's very important if you're ever asked to do a medical exam, whether it's a firefighter applying to the training academy or his annual return to work, make sure you truly understand what you're clearing them to do and all the potential risks involved in those activities. So how can, as occupational medicine physicians, how can you reduce the risk of cardiovascular disease in your firefighter patients? Just like with any of your patients, you want to go to the modifiable risk factors first and try to address them. Certainly physical fitness and obesity is something most people need to work on. There is this document here. It was put out by the International Association of Firefighters. That's the main firefighter union. And in conjunction with the International Association of Fire Chiefs, this wellness fitness initiative, they're currently in their fourth edition, which came out in 2018. And this sort of goes into a holistic approach to fitness and health. So it's not just, you know, doing your physical fitness. It's taking care of these other aspects of your life to be overall in better health. Many fire departments now have workout facilities at the fire station. You may get called away during your shift, but after your shift is over, especially if it was a slow time, they have the facilities there to get their workouts in and help them in that regard. And some of the larger departments actually have exercise physiologists on staff that help them design their physical fitness training programs during their cadet training, as well as offer any guidance that individual firefighters may have, and to use them as a resource for slow, gradual increase of both strength and aerobic capacity, because the last thing we want to have anyone, including a firefighter, do is get the idea that they need to put themselves through a boot camp and wind up in rhabdo before they start any other job. So it's all about having that information and utilize your resources. Going specifically to what NFPA 1582 says about cardiac assessment, you start off with, just like with any other patient, looking at doing your first 12 lead EKG as your first step, and the NFPA guide says they want it done annually after age 40 or clinically indicated. Then you go through a CVD risk stratification process that you see here, and how is that risk assessment done? Well, there are two ways that they recommend doing it, either by looking at the Framingham risk tables or using this calculator widget. So this is what it looks like. You just enter in all the information, and just to give you an idea what that would look like for an imaginary patient, I just made up some numbers and put it in here and type estimate risk. And then here we go for this imaginary 45-year-old. He has a 12.6% 10-year risk of ASCVD. So what do I do with that information? Well, if we find by either of those methods he's at increased risk, we move on to the exercise stress test. It is done specifically both symptom-limiting and also has to include imaging study. And that can vary whether you want to do it in tandem with an echo or a technetium scan, whatever. It just has to be some sort of imaging study in conjunction with the symptom-limiting aspect of it. They have to achieve 12 METs. So this was written according to the standards at the time the incident happened. So those were the older standards. If you attended Dr. Zarnecki's talk yesterday, you could see that that is changing as far as different METs requirements. So I will not get into that quagmire here. But this is what was in place at the time of the example fatality I'm going to give you. And if they're positive, refer immediately to cardiologists. And if negative, repeat periodically. And there is some inclusion about using coronary artery calcium scores. But it really doesn't go into detail other than this may be another adjunct test you could use for a risk assessment. It's also important, as with any test, to know the limitations of your test. So the exercise stress test is great at identifying blockages when you wind up with evidence of ischemia, but not so helpful if you don't. So if you have a positive test, that really tells you they have an active or significant lesion that needs to be addressed right away. But just because they have a negative test doesn't mean they're in the clear. And it also, when you go over this with your patients, have to remind them that this is a snapshot in time. You may have had a negative test a year or two years ago, but that doesn't tell me or guarantee you having shiny, clean arteries right now. So it's really important to refresh their memory of what this test does and does not tell them, which plays into the example we're going to go over right now. So this was a 32-year-old firefighter. He was an apparatus driver, worked at his local department for over a dozen years. And one of the reasons why this caught my attention, because it happened around the same time we're at now during the year, Memorial Day weekend. So back in May 30th of 22, he was last seen on the camera inside the station going to his bedroom. He was a full-time employee. He had his own bedroom with attached bathroom suite there. He had been planning to meet up with family and friends, and even with the fire chief who had a boat, to take his boat out on the lake later that day. And his father was going to meet him out there. Well, later that morning, about an hour later after he was last seen on camera, he talked to the chief, said, you know, he wasn't feeling well, felt nauseous, sweaty, said he thought he would feel better if he could just throw up. But the chief asked, well, do you think it's a flu or COVID, because we're, you know, pretty still into COVID at this time? No, I'll just feel better. Let me go get some sleep. And he let his dad know that he wouldn't be joining them at the lake for the boating outing. Well, they couldn't get a hold of him all day. And the next day, the chief and the dad went to the station to try to find him, see what was going on. His truck had been parked there, hadn't moved all day. And unfortunately, he was found deceased in his bunk room. He had his negative exercise stress test two years ago, and actually did pretty well, got 12.4 meds on there. Now, there was no documentation in the fire department medical records that he had any other medical conditions. But in his belongings, they found a prescription bottle for etanol, and then finding on autopsy consistent with Graves' disease. He was borderline overweight. He was no substance use, no tobacco, ethanol, or drug use. And when they did his autopsy, 100% LCA occlusion. Some of the key recommendations we made in this investigation, and usually with our fatality reports, we have two parts of our recommendations. One is pretty much as a standard for good practice, we reference the relevant NFPA standards about medical screening and things like that. But then we also tie in recommendations specific to this particular event. And this really focused on looking at heart attack signs and symptoms. If you had a patient of his age who said he was having chest pain and felt nauseous, what would you tell them to do? Tell them go to the ER, get checked right away. And especially when the chief asked about, well, did he think it was a flu? Well, he didn't report any fever, URI symptoms. And for me, that was like, huh, that would have been the reason to not let him go to sleep and get him into the ER right there and then. But it's always easy to tell that to somebody else versus when it's happening to yourself and you don't want to think it's happening to yourself. So unfortunately, on several of the fatality cases I've done, you want to emphasize that if you develop symptoms yourself, that could be a heart attack. Or if you see one of your co-workers report symptoms consistent with a heart attack, stop, do not pass, go, reinforce the need. If you would tell this to someone on the street to go get checked out right away, you should be doing this too. And unfortunately, this is not the first type of fatality that we've seen like this where there may have been a decision branch point where they were exhibiting or reporting signs and symptoms consistent with an MI that were just, you know, not caught and let go. One of the things in the NFPA standard, if you've never had a chance to take a look through it, it's very thorough. It goes through pretty much every, like a review of systems where it talks about every type of, well not every type, but very common types of disorders in each system and what would be immediately disqualifying versus something they could work with depending on how it impact their ability to complete those essential job tasks. Well, they have a section in there on their endocrine and there's certainly recommendations on how some extra screening for Graves' disease and or Hashimoto's thyroiditis, but there was no evidence that the department was aware that he had this. So some of the other things we could look at in your patients are improved nutrition. There's certainly been a move in the last several years to educate firefighters, bring on nutritionists, and actually some fire training academies actually include nutrition teaching in the cadet didactic program. So they get this from the very start to how to, you know, if you want to do family style meal that's all well and good, but, you know, let's try a little, make it healthier rather than, you know, gravy and biscuits piled up, as well as focus on your portion sizes. Yes, firefighters do burn a lot of calories in doing the strenuous work that they do, but it also needs to be balanced off with, like, managing your intake. There are apps coming up, like the one mentioned below, but one of the main intervention points that I found is pretty much at every department you see they run on coffee. Their nutritional pyramid starts with caffeine at the base. So if there's any sort of low-hanging fruit to get to, just to reinforce the idea that, you know, you may not necessarily need a case of five-hour energy to get through your shift, you know, to help reinforce those messages. Ask about their dispatch alert system. You know, so many companies have gotten on this bandwagon on creating, you know, less jarring systems in how to alert firefighters to calls. In fact, some of them, and one of them could have worked in this case where you had, this firefighter had his own dedicated room because he lived at the station full-time. Some of these dispatch systems are fancy enough that you can actually have them only alert the staff in their individual rooms that are being dispatched. So you don't wake up the entire station with the dispatch notice, you just wake up the people who need to get going. There's also these graduated ramp-up light systems so you don't get that whoosh of floodlamps going on in your bunk room. So there's a whole different way you can approach to help sort of less, you're never going to remove the startle factor, but maybe lessen some of that catecholamine response on how you actually wake them up. And last, but certainly not least, is this issue with coping with stress. As occupational medicine physicians, you are in a great vantage point of being another ear for them, as well as being another voice telling them it's okay to get help. Here are some resources. It's not just you. If you don't want to talk to EAP, there are other resources like this one here. The IAFF has created this 24-7 confidential helpline, especially in light of some of the experiences with EAP. By having their own staff man these hotlines, the firefighters know when they call into this line, whoever answers that call will get it. They will understand what they're talking about. They will understand the challenges that they face in particular situations without them having to go into a whole background explanation of it first. Many have used this IAFF line as well as the department's own peer counseling as primary support networks. So if you're just another voice in their ear telling them if you're having difficulties, if you're self-medicating in whatever way, there is assistance available for you in a way that's hopefully not incurring any stigma to it. So just being another repetitive voice in their ear about this is always a great thing. So in conclusion, if you're ever asked to do a medical exam for a firefighter in any part of their career lifetime, it's really important to familiarize with these essential job tests as listed in 1582 to make sure you're knowing what you're assigning them as being cleared to do. We want to always address any modifiable risk factors that we can and hopefully provide some personalized risk reduction plans instead of giving them, oh here, just check this website and reduce your risk factors, no, no, no. Having this one-on-one counseling time can be very helpful with them to know where should they put their immediate attention to, what could help them the best way first. And just to have that repeated intervention that, okay, you're doing well here, but here's now what we need to focus on. So just that it's a constant conversation. And lastly, remind them it's not just your patients that have heart attacks, your staff, your colleagues, and you could certainly wind up in that situation. And if you do, please, please don't blow it off. If you would tell a patient or someone on the street to get checked, get yourself checked because really when it comes down to it, this is how you want the firefighters to end their career with a retirement party rather than a funeral. Thank you. And I put on the right a little information about our resident rotation program. Our window opens July 1st to September 1st and you can go on the website as listed there or if you have any questions, feel free to shoot me an email. Are there any questions on the presentation? Yes, sir. Could you come up, please? Hi. Great presentation. Very important topic. Just wanted to confirm you're recommending a stress test annually with the physical exercise stress test? That's what the, after age 40. Okay. Yeah. And those again are NFPA consensus standards, what we'd like them to do if at all possible. Okay. Yeah. All right. Any others? Yes. Hi. Thanks for the great lecture. I have a couple questions. One, there's a big hubbub about the PFAS. If you can please, yeah, please say something because I do firefighter exams and I have a couple questions. If you can please, yeah, please say something because I do firefighter exams and I have a couple questions. One, there's a big hubbub about the PFAS. If you can please, yeah, please say something because I do firefighter exams and I'm seeing this anxiety in the fire chiefs and the fire departments to get all the possible testings about ... And then there's one, another one, which is called GALLERI, G-A-L-L-E-R-I. Apparently they're getting a lot of grants for this test and it's about $1,000 a test. It's a blood test. And there's this only one lab that does that, if you have any knowledge of that. And the third, is there any new NFPA regulations coming in that you are aware of that are meaningful or ... Well, I think with PFAS, especially with some, there's been some discussion about having a sort of presumptory coverage of health conditions. But I think there's always danger in that is that you always want to take good care of your firefighters, but you want to have good evidence-based medicine on which to do it. And the first step in that is scientific data. And one of the other programs that NIOSH runs is the National Firefighter Registry for Cancer. And it is an exposure database. So that we've been trying to enroll. There's over 10,000 enrolled so far, to get an idea of what they're actually exposed to, so that those studies that look at specific exposures and their potential health effects can be started. And I think we're really just at the beginning of the process of developing the scientific data on which to base recommendations. But I understand there's always that concern that, you know, we think this is a problem, we want to get them covered now. And I think that that is always a concerning approach to take when you don't have all the data to back up that action. And I feel for you. It's a very difficult situation. I mean, this is similar to what happened after 9-11, that, you know, nobody knew what was in that pile of, you know, airplane fuel parts, building parts. But there was a lot of presumptive coverages of health conditions. Let's just assume that they got it from there. And it is a difficult situation. And if you contact me later, I can send you what we have. I'm sorry, I can't give you a definite answer, you know, as what would NIOSH recommend in that way as far as specifics. Sure, I can email you and definitely you can send me more. But do you have any comments on the GALADY? Have you heard of that? I am not familiar with that. Again, my primary job is to use fatality investigations, and that's not something we come in contact with. So, I'm sorry. Thank you. Any other questions? No? Well, I want to thank everyone for attending despite the late start. Oh, sorry, sorry. Yes, we should never underestimate the importance of, you know, discussing healthy lifestyle modification. I work in Beaufort, and last year when I saw one of the firefighters, I work at the Naval Hospital. And as I always do, you know, talk to them about what I call the firefighter diet. And so, I challenge them and their colleagues. And one of the firefighters, they had a competition going on. One of the firefighters lost 40 pounds over about a four-month period, and they enlisted, you know, their colleagues. And so, they had a competition going on. And it's impactful, you know, what that has to do. The other comment I want to make is about when I started practice with, they were volunteer firefighters, and they didn't understand why they had to be under the, you know, same, not restrictions, but requirements. And I told them, I said, the fire doesn't know if you're paid or volunteer. So, that therefore, you're putting yourself at risk, and also the people you're going to rescue. So, try to do the very best, because some of them don't have health insurance. But try to do the very best about, you know, the modifiable risk factors. That's why that joint publication with the IFF and the National Volunteer Fire Council is so helpful, because it does give them information on resources they can use that they might not have access to, but how they can get around that to provide the services their firefighters need and should have. So, I absolutely agree. Whatever you can do with that. Many departments also offer, you know, deals with gyms. Their local gyms have been willing to host memberships, or some of the health insurance offers, like they do for pretty much all their patients, you know, financial incentives for weight loss and things like that. But yeah, any way you can get them to reduce those modifiable risk factors is great. Thank you. All right. Well, thank you, everyone. I hope you have the rest of a good day. Thank you. Thank you. Have a good day.

cardiovascular disease risks

firefighters

stress

physical demands

obesity

stress management

nutrition

occupational health physicians

risk reduction strategies