A COORERATIVE APPROACH TO BUILDING A HEALTHIER FIRE SERVICE
Editor`s note: The objective of The Fire Service Joint Labor Management Wellness/Fitness Initiative is to “build and maintain fit uniformed personnel,” according to the document`s foreword, and to create a fire service health and fitness database. A summary follows. Copies may be obtained through the International Association of Fire Chiefs at (703) 273-9815, ext. 322, or the local president or secretary of the International Association of Fire Fighters. The Initiative is copyrighted by the International Association of Fire Fighters.
The Fire Service Joint Labor/Management Wellness/Fitness Initiative is a response to concerns about firefighters` health. The high stress, intense physical demands, and long-term exposure to chemicals and infectious disease associated with firefighting contribute to heart disease, lung disease, and cancer–the three leading causes of firefighter death and occupational disease disability. The nonpunitive Initiative encompasses medical, fitness, injury rehabilitation, behavioral health, and data collection and reporting components. All personnel medical and fitness data are confidential; employers may access only information relating to personnel fitness for duty, necessary work restrictions, and appropriate accommodations. It is a cooperative effort between the International Association of Fire Chiefs (IAFC), the International Association of Fire Fighters (IAFF), and the fire chiefs and labor representatives of 10 municipal fire departments around the United States and Canada* that have mandated member participation in this program.
MEDICAL
Management and Labor shall support the provision of comprehensive mandatory annual medical exams by the fire department as a component of the wellness program.
Ideally, the fire department physician should be board-certified in occupational, internal, or family medicine; be knowledgeable in a relevant specialty (e.g., cardiopulmonary medicine, burn care); and have a thorough knowledge of job-related activities and their medical aspects. The physician must intervene to prevent illnesses and injuries, follow up on abnormal findings in the annual physical, make return-to-work determinations, and provide written feedback to personnel following annual examination.
Medical Examination
The mandatory exam should be performed every 12 months within one month of the annual due date. Through the medical exam the department physician determines if a member can physically and mentally perform essential duties without undue risk to himself or others; monitors the effects of exposure to specific biological, physical, and chemical agents; detects changes in an individual`s health possibly related to harmful working conditions; detects possible work-related disease patterns; educates individuals about occupational hazards and current health; provides a cost-effective investment in early detection, disease prevention, and health promotion; and complies with federal, state, provincial, and local requirements.
The results of the medical examinations will be compared with the individual`s initial preemployment medical history questionnaire that establishes baseline information with periodic medical histories providing follow-up information and periodic questionnaires focusing on changes in that individual`s health over time.
The Initiative allows data gathering on uniformed personnel in this occupational group throughout their careers. Comprehensive confidential medical information will be collected for purposes of this Initiative. An integrated exposure database in which the department physician receives timely information on uniformed personnel aids in tracking diseases in individuals and risks in the population. The physician must educate firefighters and EMS workers on the importance of documenting exposures and follow-up care to ensure the employee gets the necessary medical care. The central department database must include chemical exposures, physical exposures, biological exposures, and all safety/health-related incidents.
The physical examination includes personal invasive exams that some personnel may prefer having their primary-care physicians perform; the results must be forwarded to the department physician.
The hands-on physical includes the vital signs; head, eyes, ears, nose, and throat (HEENT); neck; cardiovascular; pulmonary; gastrointestinal; genitourinary; rectal; lymph node; neurological; musculoskeletal; and body composition examinations.
Vital signs. Vital signs include blood pressure, body temperature, pulse, and respiratory rate. Blood pressure should be part of the baseline and periodic exams.
Head, eyes, ears, nose, and throat (HEENT). This determines a firefighter`s general fitness for wearing headgear, face piece, and breathing equipment, identifying any chronic exposures that may put the patient at risk for long-term illness.
Cardiovascular. The basic cardiovascular exam starts with a thorough history including any recent change in the patient`s work capacity, which is important in early screening of pulmonary and cardiac disease. A cardiac performance baseline should be established and any cardiac risk factors including age, sex, prior myocardial infarction, elevated cholesterol, family history, smoking, or diabetes noted. A resting EKG is a necessary part of an annual exam.
Pulmonary. In the pulmonary exam, baseline spirometry must be assessed in all personnel who may need to wear breathing apparatus and is useful for individuals with a history of respiratory health problems as a baseline for later comparison. A baseline chest X-ray for healthy personnel may be used for comparison if a disease develops later. It is recommended every three years and required every five years.
Gastrointestinal. General evaluation items include feeling for evidence of hernias, liver, colon, gall bladder, and spleen diseases and evaluating the abdominal vascular structures; the normal movement of gas through the hollow organs; and abnormal sounds around the aorta, renal and iliac arteries. For women, the lower abdominal exam, combined with a pelvic exam, provides information about the ovaries, fallopian tubes, and uterus.
Genitourinary. In men, annual testicular and hernia exams are important. For women, the exam must include a pelvic exam, a Pap smear, and a breast exam.
Rectal. All personnel must receive a digital rectal exam (DRE). Men with a significant family history must be counseled about annual screening and the prostate-specific antigen (PSA) blood test. Fecal occult blood testing (FOB) via the DRE is effective for colorectal cancer screening in men and must be part of the physical exam. Female personnel should be evaluated for lower intestinal nodules or masses.
Lymph nodes. Regional exams (e.g., the neck) should be supplemented with appropriate lymph node examination in the specific region.
Neurological. The neurological exam for uniformed personnel must include a mental status evaluation and general assessment of the major cranial/peripheral nerves (motor, sensory, reflexes). The mental status exam focuses on orientation, memory (short- and long-term), intellectual performance, and judgment.
Musculoskeletal. This exam is one method of defining short- and long-term postinjury limitations. Evaluating and documenting preemployment, work-related limitations is important for predicting job performance and may affect potential future disability claims, so the examination must be accurate, including an overall assessment of the range of motion of all joints. Joint mobility may be determined through certain standard office exercises and functions.
Body composition. Body composition refers to the relative amounts of body fat and lean body mass. Excess fat increases workload and amplifies heat stress by preventing efficient heat dissipation; elevates the energy cost of weight-dependent tasks (e.g., climbing a ladder or stairs); and may also cause lower back injury, myocardial injury, hypertension, diabetes, and unexplained breathlessness. Circumference measurements determine body composition and are the primary indicator for the purposes of the Initiative.
Recommended Annual Prephysical Laboratory Tests
The following tests are included in the annual physical exam:
–Blood analysis. Personnel should have their blood drawn and analyzed at an appropriate lab. Note: The blood drawn for analysis is not intended to be and will not be used for drug use screening at any time.
–Liver function tests.
–Cholesterol.
–Heavy metal screening (blood and urine).
–Urinalysis. Note: The urine sample received for this analysis is not intended to be nor will be used for drug use screening at any time.
Cancer Screening Elements
Invasive examinations (e.g., breast exam, Pap smear, DRE, FOB, testicular exam) must be conducted with the annual exam. Personnel may have the exams done by an outside physician and the results forwarded to the department physician.
Cancer-screening test include the following:
–Breast examination/mammogram.
–Pap smear.
–Prostate specific antigen (PSA).
–Digital rectal exam (DRE).
–Fecal occult blood testing.
–Skin exam.
–Testicular exam.
Immunizations and Infectious Disease Screening
Vaccinations. Personnel must provide proof of up-to-date vaccinations for tetanus/diphtheria, measles, mumps, rubella, and polio. The following should also be included:
–Tuberculosis.
–Hepatitis A virus.
–Hepatitis B virus.
–Hepatitis C virus.
–Varicella (chicken pox).
–Tetanus/diphtheria.
–Influenza.
–Measles, mumps, and rubella (MMR).
–Polio.
–HIV. HIV testing is not part of baseline or annual physicals. Test should be offered confidentially as part of postexposure protocols and as requested by the physician or patient. All HIV results are sent directly to the patient and will not be maintained in any local or international database.
FITNESS
Management and Labor shall work together to provide workout scheduling, resource support, and/or access to resources on duty to support an individualized fitness program.
Fitness Program Components
–Medical clearance. Personnel must be medically cleared to participate before the fitness assessment.
–Fitness evaluation. All members must participate in a mandatory annual nonpunitive and confidential fitness assessment following medical clearance.
–Dedicated time for exercise. For every shift, 60 to 90 minutes should be set aside for exercise. Personnel working a 40-hour or similar shift should also be allowed time to exercise.
–Equipment and facilities. Adequate equipment and facilities for a complete, balanced program must be available. Equipment should include leg press, curl, and extension machines; bench press and adjustable bench; lat pulldown/seated row machine; minimum 300-pound weight assortment; five- to 60-pound dumbbells; curl bar; and floor mat. Additionally, included should be commercial aerobic machines such as treadmills, stationary bikes, stair steppers, and rowers, as well as walking or running exercises.
–Fitness committee. This should include labor, management, the department physician, and a certified exercise specialist.
–Peer fitness trainers (PFTs). Peer fitness trainers are trained by an exercise professional and encourage fitness safety and participation through guidance and supervision of personnel exercise. Professional certification is recommended.
Fitness Evaluation
The fitness evaluation is geared to the individual`s improvement and not to a standard. The exercise specialist should report to the member and the department physician regarding the individual`s physical capacity, current fitness level, improvement since previous assessments, ability to safely perform duties, and a suggested progressive exercise program. It must be followed by a one-on-one consultation in which the individual can address concerns and learn about recommended exercises and equipment.
The following information should be included:
–Aerobic capacity.
–Flexibility.
–Muscular strength.
–Grip strength.
–Leg strength.
–Arm strength.
–Muscular endurance.
The data collected from fitness assessments will identify changes in fitness over careers, medical and fitness program effectiveness in improving individual physical fitness, muscular weaknesses and imbalances in the individual that if corrected will prevent injury, possible causes of sprains and strains, risk factors for back injury, and possible factors related to high incidence of musculoskeletal injuries in the fire service.
INJURY/FITNESS/MEDICAL REHABILITATION
Management and Labor shall work together to provide a progressive individualized injury/fitness/medical rehabilitation program that shall ensure full rehabilitation of any affected uniformed personnel to a safe return to duty status.
Rehabilitation must be a priority and may be in-house or outsourced. Criteria for programs include the following:
Fire department medical liaison familiar with job requirements and fit-for-duty expectations.
A physical therapy organization familiar with job requirements and fit-for-duty requirements.
An alternate duty program.
Periodic reevaluation following return to duty.
Personalized exercise prescription that considers the individual`s job requirements and past medical history.
Comprehensive injury prevention program.
The fire department should ensure that all uniformed personnel are properly rehabilitated before returning to full duty. Physicians and physical therapists familiar with firefighting job requirements should make informed decisions regarding functional capacities of personnel after significant injury or illness. Personnel on continuous extended leave status from duties for six months or more must undergo medical and fitness evaluations before returning to full duty.
A physical/occupational therapist must have a thorough knowledge of the physical therapy aspects of firefighter job requirements. When appropriate, job-oriented task performance should be part of rehabilitation and programs should be guided by standardized treatment that should be age-, gender- and position-specific, ensuring therapy consistency and cost control. The program should start as soon as the person is injured. Standardization should be incorporated into defined research protocols to permit long-term analysis of the clinical and administrative effectiveness of treatment. An alternate duty program should use the skills of injured or ill personnel during rehabilitation. This will reduce costs and keep the individual involved with the department while using the individual`s expertise. Personnel should be assigned a peer fitness trainer and placed on an appropriate mandatory rehabilitation program.
Injury Prevention Program
An injury prevention program requires a labor/management committee (an extension of the safety committee) that consults with appropriate outside experts (i.e., department physician, a biomechanical engineer, a physical/occupational therapist). A proactive injury prevention approach should include the following:
Comprehensive and effective wellness program.
Physical fitness program.
Strong commitment to safety by labor and management.
Ergonomic analysis of all job aspects to redesign the work environment more effectively.
Education to begin in the academy and continue throughout the career.
Recognition system for personnel who practice, play, and preach safety.
BEHAVIORAL HEALTH
Management and Labor shall support the provision of a behavioral health plan that may be delivered either through internal or external sources, based on specific elements.
A mentally and emotionally fit firefighter and EMS provider is an important building block in the service`s foundation. Alcoholism, drug addiction, death of a coworker, financial distress, marital/family problems, and occupational stress may affect personnel on and off the job.
Health promotion programs should address weight control, nutrition, cholesterol control, tobacco-use cessation, fitness, stress management, hypertension, preventative medicine, infection control, substance abuse, retirement planning, and work-related issues. All behavioral health services must ensure confidentiality.
A behavioral health specialist should be a psychologist or counselor with a master`s degree, several years` experience in occupational counseling, and familiarity with the unique stresses and psychosocial elements of the fire service. The specialist should develop, coordinate, and oversee programs; offer a voluntary confidential behavioral health evaluation covering stress, alcohol/substance abuse, and personal or work problems; and offer assistance with these problems for an immediate family member. The specialist should survey personnel, meet with individuals, and offer counseling for any identified problems.
The behavioral health specialist should counsel and refer individuals promptly to behavioral health care services such as the following:
Assessment and referral.
Outpatient counseling.
Outpatient substance abuse treatment.
In-patient chemical dependency, including detoxification.
Psychiatric evaluation and treatment.
In-patient behavioral counseling and suicide prevention.
Financial counseling and debt consolidation.
Tobacco-use cessation classes.
Critical incident stress management counseling.
Some of the services may be available through a comprehensive employee assistance program (EAP) or from contracted agencies through the employee`s health plan. The behavior health specialist should coordinate these arrangements. Comprehensive follow-up and periodic maintenance visits will give personnel additional support, and the department`s behavioral health program should have access to a variety of 24-hour help resources.
Obesity, bulimia, anorexia, and other severe conditions require a certified nutritionist, physician, or psychotherapist to implement a behavior modification program.
Personnel with alcohol or substance abuse problems should receive whenever possible early intervention with referral to a credible substance abuse program. The department`s substance abuse policy should be clear to applicants and include ongoing education. Treatment at a reasonable cost should be available to those needing it. Drug testing is not part of this Initiative, however, and should not be part of the physical or blood/urine tests.
The Initiative says all new candidates shall be tobacco-free on appointment and throughout their length of service to the department and that current personnel shall not use any tobacco products on the worksite, in or on department apparatus, or inside training facilities. A department-sanctioned nonpunitive tobacco-use cessation program should be available to tobacco users.
Prevention is important in stress management and may be incorporated into the training of new recruits and annual company training. Potential hires may undergo psychological testing; periodic psychological testing could identify individuals with high stress.
An EAP is a cost-effective humanitarian, job-based strategy for helping employees with personal problems affecting their work performance. The EAP should be incorporated into the total wellness concept and address potential weaknesses. A primary assistance need may include underlying problems also needing attention. An effective EAP should restore personnel to a healthy and productive life, improve employee morale, and increase productivity. It may be accessed through employee request, supervisor suggestion, adverse employee job performance, or an agreement making EAP participation a condition of employment. Complete confidentiality and assured job security or promotion should not be jeopardized.
Federal Title 42 requires employee record confidentiality in any organization using federal funds. Many states have specific legislation addressing provider-patient privilege for licensed health care providers. But when public or personal safety is an issue, relevant information must be shared with the department physician.
Rehabilitation, not termination, of impaired personnel is the most effective and compassionate means of retaining a valuable member of the department. The program must be strictly confidential.
DATA COLLECTION
All personnel data collected by the International Wellness/Fitness Database is confidential. Individual identities are not submitted by the department for any job history, annual medical or fitness evaluations, or injury data. The data component of the Initiative includes the storage and analysis of detailed case information related to medical condition (exam/laboratory data), fitness, rehabilitation, and behavioral health.
Uniform, effective, and efficient collection of information from participating fire departments and compilation in an international database for analysis are key elements in this component. The goal is to collect long-term health and fitness information that quantifies the firefighter`s medical/fitness history and determines the effectiveness of the wellness/fitness programs. n
Endnote
* The fire departments involved include those of Austin, Texas; Calgary, Alberta, Canada; Charlotte, North Carolina; Fairfax County, Virginia; Indianapolis, Indiana; Los Angeles County, California; Metropolitan Dade County, Florida; City of New York, New York; Phoenix, Arizona; and Seattle, Washington.
MISSION STATEMENT
Every fire department in cooperation with its local IAFF affiliate must develop an overall wellness/fitness system to maintain uniformed personnel physical and mental capabilities. While such a program may be mandatory, agreement to initiate it must be mutual between the administration and its members represented by the local union. Any program of physical fitness must be positive and not punitive in design; require mandatory participation by all uniformed personnel in the department once implemented; allow for age, gender, and position in the department; allow for on-duty-time participation utilizing facilities and equipment provided or arranged for by the department; provide for rehabilitation and remedial support for those in need; contain training and education components; and be reasonable and equitable to all participants. The program must address the following key points:
Confidentiality of behavioral, medical, and fitness evaluations.
Physical fitness and wellness programs that are educational and rehabilitative, not punitive.
Performance testing that promotes progressive wellness improvement.
Commitment by labor and management to a positive individualized fitness/wellness program.
Development of a holistic wellness approach that includes
–Medical evaluation
–Fitness
–Rehabilitation
–Behavioral health.
The program should be long term and, where possible, be available to retirees.
