Fitness-For-Duty Assessments of Industrial Firefighters: Guidance for Occupational Medicine Physicians

ACOEM GUIDANCE STATEMENT

Fitness-for-Duty Assessments of Industrial Firefighters: Guidance for Occupational Medicine Physicians

Faiyaz A. Bhojani, MD, MPH, DrPH, Luis A. Castillejo-Picco, MD, MS, PhD, David Cathcart, DO, MPH, Edward A. Emmett, MD, MS, Stephen Frangos, MD, MPH, P. Mark Glencross, MD, MPH, Chris J. Herman, CFPS, Kevin O’Shea, MD, MPH, Paul Rountree, MD, and David E. Turner, MD, PhD, MPH, MBA, ACOEM Task Force on Fitness-for-Duty Assessments for Industrial Firefighters

Industrial firefighters share many characteristics industries to develop fitness-for-duty guid- The questionnaire was reviewed by with municipal firefighters; however, employers ance for industrial firefighters and address the University of Pennsylvania Institutional frequently have not addressed or characterized the the lack of standards and guidance specific Review Board (IRB), which concluded the unique job duties, hazards, and specific physical/ to this population. This lack of a standard- project did not meet the criteria to be mental demands associated with industrial fire- ized approach could result in firefighters considered human research and was thus fighting. In addition, gaps exist in the medical being improperly assessed for their capa- exempt from further IRB oversight. The literature with regard to industrial firefighter dem- bility to safely perform industrial firefight- Task Force engaged ORCHSE Strategies, ographics, behavioral risk factors, and chronic ing duties and puts the firefighter, his/her LLC, a health, safety, and environmental diseases. Finally, the proper methodologies for coworkers, the workplace, and the commu- control network that sponsors a cross- fitness-for-duty assessment of employees acting nity at risk. This increased risk has the industry forum for purposes of benchmark- in this capacity are lacking. To address these gaps, potential for increased liability to business ing and sharing best practices, to host the the American College of Occupational and Envi- entities employing industrial firefighters. online questionnaire. ORCHSE member ronmental Medicine (ACOEM) convened a Task In addition to recommending best companies reached out to their firefighters Force in 2014, to develop fitness-for-duty guid- practices for the determination of an indus- to complete the questionnaire. No identi- ance for industrial firefighters. This document trial firefighter’s fitness-for-duty, an impor- fiers were included in the questionnaire and highlights these gaps and suggests research oppor- tant part of the Task Force’s charge was to data collected were anonymous and confi- tunities to enhance the health and safety of this characterize where possible, the demo- dential. The Task Force members received population. While an extensive literature review graphic make-up of the industrial fire- only aggregate responses to the question- found a lack of studies for this population—thus fighter. Such knowledge is essential to naire for analysis. excluding the development of an evidence-based differentiate industrial from municipal fire- The Task Force identified five ques- document—sufficient materials were available fighters particularly as it may relate to tions for systematic literature review to from which to draw preliminary conclusions, con- cardiovascular disease, the most common document the current state of affairs in each siderations for best practices, and recommenda- cause of work-related mortality among area: tions for future studies. municipal firefighters. As an additional benefit, this information has the potential 1. What are the differences in job duties for n October 2014, the American College for conducting directed studies that will municipal versus industrial firefighters? I of Occupational and Environmental advance the health and safety of the indus- 2. How can cardiovascular fitness for duty Medicine (ACOEM) convened a Task trial firefighter population. be best determined for industrial fire- Force of medical practitioners, corporate fighters? medical directors, university professors, 3. Are tools currently used to determine and fire chiefs having a working knowledge METHODOLOGY fitness for duty useful? of US oil and gas and petrochemical Task Force members identified a list 4. What preventive interventions are avail- of questions (identified under the section on able and how effective are they? Topics Reviewed) for which the systematic 5. How do US laws impact fitness-for- From the American College of Occupational and literature review would seek to document the work decisions? Environmental Medicine, Elk Grove Village, current state of affairs. Literature searches Illinois. utilized Medline, PubMed and PubMed Cen- This position paper was developed by the ACOEM DIFFERENCES IN JOB Task Force on Fitness-for-Duty Assessments for tral, and National Library of Medicine data- Industrial Firefighters, under the auspices of the bases to identify and characterize the DUTIES—MUNICIPAL VERSUS Environmental Health and the Underserved relevant literature for industrial and munici- INDUSTRIAL FIREFIGHTERS Occupational Populations sections, reviewed pal firefighters, identify gaps that exist for As previously noted, fitness-for- by the Committee on Policy, Procedures, and Public Positions, and approved by the ACOEM the industrial firefighters, and advance rec- duty standards and guidance specific to Board of Directors. ACOEM requires all sub- ommendations to address literature gaps. the industrial firefighter population is lack- stantive contributors to its documents to disclose The Task Force then designed a ing. The National Fire Protection Associa- any potential competing interests, which are questionnaire (Appendix 1) for industrial fire- tion Standard on Comprehensive carefully considered. ACOEM emphasizes that the judgments expressed herein represent the fighters to identify the following information: Occupational Medical Program for Fire best available evidence at the time of publication Departments (NFPA 1582), does not and shall be considered the position of ACOEM demographics include industrial fire brigades in its medi- and not the individual opinions of contributing level and frequency of firefighting duties cal assessment standard.1 The NFPA 600 authors. The authors declare no conflicts of interest. patterns and frequency of training Standard on Facility Fire Brigades contains Address correspondence to: Marianne Dreger, MA, variations in the medical clearance only minimal reference to the medical ACOEM, 25 Northwest Point Blvd, Suite 700, process clearance process.2 This lack of guidance Elk Grove Village, IL 60007 ([email protected]). access to and involvement in employer- has contributed to the presence of multiple, Copyright ß 2017 American College of Occupa- tional and Environmental Medicine directed regular fitness activities differing firefighter assessment methodol- DOI: 10.1097/JOM.0000000000001256 risk factors for cardiovascular disease ogies across various industries.

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NFPA 600 classifies facility fire bri- strength but the heavier nature of the equip- whereas the primary tool for industrial fire- gades as either incipient stage firefighting, ment may put industrial firefighters at fighters is foam which is used to fight class B advanced exterior firefighting, or interior increased risk for back injuries. and C fires (flammables/electrical). structural firefighting.2 The incipient stage Industrial firefighting is also signifi- Municipal firefighters have a involves fighting a fire in normal clothing cantly different from community firefighting broader scope of job duties. As job duties using extinguishers or smaller hand lines in that the knowledge required is more spe- are more narrow for industrialized fire- (125 gpm). It also requires no evasive cific for the local setting (eg, explosive, fighters, there may be more opportunity actions (eg, crawling to escape heat or chemical, or marine situations). Municipal for accommodation of various medical con- smoke), and does not necessitate the use and industrial firefighters wear standard ditions.6 There is a different skill set as well of bunker gear or self-contained breathing structural firefighting clothing whereas between the two.8 Municipal firefighters apparatus (SCBA).2 Advanced exterior or industrial firefighters’ clothing may include are trained in rapid intervention and team interior firefighting involves full gear, high temperature protective and chemical concepts, accountability systems, and teams in warm and hot zones utilizing protective clothing.5 Resulting dehydration search procedures. Industrial firefighters SCBA, attack teams of two or more, estab- and hyperthermia are often a greater issue for deal more with confined space rescue and lished communication systems, experi- industrial firefighters particularly in those must have knowledge of the properties of enced members overseeing those less with poor cardiovascular conditioning and pressurized gas fires and large scale flam- experienced, and the requirement of annual chronic disease. In the survey developed by mable liquids. Additionally, industrial fire- live fire drills. NFPA 600 states that facility this Task Force, the majority of industrial fighters are frequently trained in high-angle fire brigades are exposed to the same degree firefighters who have been community fire- rescue. Table 1 describes other differences of hazard as community firefighters, but fighters feel the physical work is similar, but that may exist. these hazards do not extend beyond the the mental demands and danger are greater The literature review, completed sur- private facility where they work.2 per episode of industrial firefighting. vey, and interviews, found industrial fire NFPA statistics from 1996 to 2000 In larger cities, municipal/structural brigades to be as diverse as the companies have found that the risk of death in commer- firefighters are generally full-time paid for which they work. While the scope of cial fires exceeds residential fires by more positions, whereas industrial fire brigades duty may be limited to handling fire extin- than 60%.3 Calls to industrial fire depart- and smaller city municipal fire departments guishers—with anything larger requiring a ments number less than 100 annually com- are part-time, volunteers called to duty only municipal fire department response—more pared with several thousand calls for when needed. Most industrial fire brigade typically, industrial fire brigades are highly community fire fighters.4 For both groups, members are plant operators or have some structured with command and control per- the vast majority of the calls are not for fires, other full time job in the facility where they sonnel, officers, and front-line firefighters. but rather for emergency medical services. work. Often, full-time paid municipal fire- As the fire chief is usually not actively To understand industrial firefighter fighters engage in an exercise regimen as engaged in fighting the fire, he/she is not job duties, the Task Force interviewed part of their regular work duties. Municipal subject to the same physical demands—not industrial fire chiefs, fire school faculty, firefighters may also plan and prepare food classifying the chief as a firefighter violates fire team medical directors, and industrial at fire stations. Occasionally, there are also the closely-knit nature of the firefighting firefighters. In general, there are many firefighter wellness and health offerings. team. However, for purpose of classifying similarities between industrial and commu- Industrial firefighters rarely have dedicated physical demands, we use the term ‘‘fire- nity (volunteer, municipal, woodland) fire- work time for exercise, meals, or wellness fighters’’ for those actively and offensively fighters. Industrial firefighters are exposed activities specifically related to the fire engaged in the isolation and removal of the to many of the same physical hazards— team. Consequently, while strength and fire source. including impaired heat exchange from health maintenance activities may be gear, sun, wind, rain, snow, extreme tem- encouraged for industrial fire teams, these HOW CAN CARDIOVASCULAR perature fluctuations, humidity, wetness, activities may need to be performed outside FITNESS FOR DUTY BE BEST mud, skin contact with oil and grease, of work hours. bloodborne pathogens, noxious odors, and Typically, municipal firefighters DETERMINED FOR respiratory irritants. Mental health stressors work 24 hours on and 48 hours off (24/ INDUSTRIAL FIREFIGHTERS? include crucial decision-making, aspects of 48) shifts or 48/96 shifts.6,7 Industrial fire In 2007, a National Institute for Occu- sustained work, unpleasant situations, and brigades on the other hand usually work 8 pational Safety and Health (NIOSH) alert, shiftwork and related fatigue. to 12 hours, often with rotating shiftwork addressed the risks of firefighters dying from Many physical demands are also sim- for 24-hour plant operations. As shift- preventable cardiovascular disease (CVD).9 ilar including the need for explosive strength workers have increased health risks for Later research supported NIOSH’s find- (running, jumping, rapid pulling, advance obesity, diabetes mellitus, and hyperten- ings.10–16 A 2014 study found 45% of on- hose line), manual dexterity (assemble sion, firefighters of all types may also have duty firefighter deaths were caused by machinery, operate hand tools, tie knots on shift-work-related health risks. CVD.17 Nearly all firefighter cardiac deaths hose, use a wrench), climbing, vision (acuity, There are also tactical differences in involve coronary risk factors—predictors depth perception, night vision, color-cod- the way fires are approached.8 Industrial include previous coronary heart disease ing), smell (leaking and burning), and speech fires tend to be larger petroleum-based or (CHD), hypertension, and smoking.10,18,19 and hearing. Municipal firefighting equip- pressurized gas fires where the emphasis is Metabolic syndrome, psychological stress, ment and hoses tends to be smaller, whereas on pipe and tank firefighting and isolating noise, sleep disorders, smoke, carbon mon- industrial fire equipment and hoses tends to and removing the source. Structural fires are oxide, cyanide, and thermoregulatory stress be more heavy duty. This means the indus- more contained, but people can be trapped are also associated with cardiovascular risk/ trial firefighter is often handling heavier inside the structure, thus requiring coordi- fitness in firefighters.20–24 Studies have loads. The physical demands on municipal nated search and rescue techniques. Addi- demonstrated that more than 40% of fire- firefighters emphasize upper body and over- tionally, the materials used to fight fires fighters exceed low CHD risk.18 Volunteer head work (‘‘overhaul’’). Industrial fire bri- differ. Municipal firefighters primarily use firefighters have the highest risk for cardiac gades tend to require less upper body water to fight Class A fires (wood/paper), fatality and CHD.25,26

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TABLE 1. General Differences between Industrial and Community Firefighters

Industrial (Excluding Incipient Firefighters) Community (Volunteer/Municipal/Woodlands)

Training Candidate ability test þþ Trained as medic/paramedic þ þþþ Training with mock fires þþþ þ Knowledge Properties of large scale flammable liquids þþþ þ Plant operations þþþ Trenching and shoring þþ þ Confined space þ þþþ Search and rescue þ þþþ Accountability systems (locate firefighters) þ þþþ Calls Calls, high volume team/dept. Under 100 per year Over 1000 per year Calls, low volume team/dept. One per 6 mo One per week Repeat responses in 24 hrs 0 þþþ Medical emergency Vast majority 2 out of 3 First due in (first on scene) 6þ, often all in 3–6 escalating rapidly as needed Some distance to get to equipment Yes No Environment Remote þ Marine þ Industrial þ Woodlands þ High rise þ Interior þ Gear Bunker gear, boots, Glove helmet, SCBA þþ Chemical suit/decontamination þþ þ (special teams) High temperature suit þþ þ (special teams) Strength Upper body work þþ þþþ Lower body work þþþ þþþ Pulling more hoses, heavier þþþ þþ Carrying hoses up, dragging injured þþþ Ladder raising þþþ Work on uneven surface þþþ Lift heavy objects off trapped þþþ Climb hillsides/shoveling þþ(wildland) Chopping with axe þþ Crawling þþ Equipment Extinguishers þþ þ Hose, number and size þþþ þ Foam þþþ þ Fixed monitors þþþ Hydrants, ladder, pumper þþ Hand tools, Jaws of life þ þþþ Fire type Chemical þþþ þ Explosive þþþ þ Fuel þþþ þ Electrical þ (high voltage) þ Wood þþþ Hazards Metal structures þþ þ Noise (pressurized fuels) þþ Electric þ (high voltage) þ Carcinogens þ (ex. asbestos) þ (ex. Benzopyrene) Chemicals (HCN, HCL, solvents) þþ þ

Key: þþþ much more; þþ common; þ occasional or present; rare or absent; SCBA, self-contained breathing apparatus. Sources: 2015 industrial fire chief interviews, Brayton Fire Training Field, College Station, TX; NFPA 1582 list of essential job tasks; and International Fire Chiefs Association’s guide to implementing NFPA 1582.

Industrial firefighting statistics and that may occur days after the events, and it industrial firefighters may have similar smaller industrial fires are frequently not is even more doubtful such information is demographic and cardiovascular risks as public knowledge.27 Firefighting statistics made available related to industrial fire volunteer community firefighters. The sur- include deaths attributed to fire response response. In the absence of complete data, vey conducted by the Task Force assessed

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health risks of male industrial firefighters goal should be considered. In other words, the climb; (2) hose drag; (3) equipment carry; who self-reported their height, weight, and same firefighting task may have higher aero- (4) ladder raise and extension; (5) forcible waist circumference. Based upon a bic demands in an individual having a higher entry; (6) search; (7) rescue; and (8) ceiling National Institute of Health risk table,28 body weight and wearing a larger size of breach and pull.59 90% were found to have increased, high, wet clothing. Fitness training programs are Industrial fire brigades may have very high, or extremely high risk for type 2 strongly recommended for firefighters their own internal guidelines for fitness- diabetes, hypertension, and CHD. although few industrial fire teams participate for-duty measurements. Royal Dutch Recent biomonitoring of industrial in formal programs.4,32,55,56 Shell’s global requirements specify mini- firefighters has demonstrated high peak aero- mum fitness and health indicators for fire- bic demands in industrial live fire simulations IS PSYCHOLOGICAL STRESS fighters and rescue teams. These include (Glencross PM, Turner D. Physiologic DIFFERENT FOR STRUCTURAL testing of visual acuity, blood pressure, the Demands of Industrial Firefighting Simula- VERSUS INDUSTRIAL cardiovascular system, and breathing appa- tions; 2016. Unpublished manuscript). Fire- ratus usage.60 Occupational Safety and fighting tasks require similar burst and FIREFIGHTERS? Health Administration (OSHA) standards sustained aerobic demands as required in There is extensive literature addressing require passing a trade test, determined by residential firefighting.29–31 In the clinical the psychological stressors of firefighting local jurisdictions, which varies by specific setting, aerobic capacity can be determined especially in first responders; however, the roles, but may include elements found in using the gold standard of metabolic testing or literature is devoid of specific studies in the CPAT such as ladder climb, victim estimated using treadmill testing using con- industrial firefighters. The Task Force’s sur- rescue, and equipment carry.61 version tables. Aerobic capacity and fitness vey identified a cohort of industrial fire- Bhojani developed a cumulative fit- are also good predictors of cardiac abnormal- fighters who had also served as community ness score ranging from 0 to 140 based on ities and risk.32–35 Maximal treadmill tests firefighters. The perception of this cohort seven parameters of fitness to determine (to voluntary exhaustion) should be used to was that the stress of industrial firefighting overall industrial firefighter fitness-for- estimate peak aerobic fitness. Submaximal was greater than what they had experienced as duty evaluation.62 These factors included: stress tests in firefighters, such as the Gerkin community firefighters (Turner D, Cathcart (1) resting heart rate; (2) diastolic blood (WFI treadmill protocol) have been shown to D, Glencross PM. ORCHSE Survey of Indus- pressure; (3) aerobic capacity; (4) body fat trial Firefighters; 2016. Unpublished manu- overestimate VO2 max and thus underesti- percentage; (5) muscular strength; (6) mus- mate potential cardiac risk and aerobic fit- script). Psychological stress in the industrial cular endurance; and (7) flexibility. All ness.36–39 Maximal heart rate formulas and firefighter is a recognized gap in the literature, seven components correlated significantly steady-state assumptions used to calculate and as such represents an opportunity for with the total fitness score even after con- research to assess the extent and impact it VO2 max tables contribute to inaccurate esti- trolling for age and experience. mates with submaximal testing. For example, may have on the health and safety of Assessments such as CPAT are geared if 40 mL/kg/min (11 METS) is used as a these individuals. toward all firefighters across industries, as fitness threshold for firefighters, submaximal the exercises are applicable in many types stress testing leads to dangerous and errone- ARE TOOLS CURRENTLY USED of situations. OSHA 1910.156(c)(2) lists ous results by suggesting that 17% to 30% of TO DETERMINE FITNESS FOR national training and educational programs unfit firefighters are aerobically fit.37,39 DUTY USEFUL? specifically for the oil refinery industry, such Elevated body mass index (BMI) Firefighters are universally subject as those at Texas A&M University and Lamar was thought to be due to many firefighters’ to a high level of physical and mental University, after which all similar programs higher muscle mass.40 However, this has stresses during their jobs. Industrial fire- should be modeled.63 NFPA has standards been disproven.41-43 While in other popu- fighters, like their municipal counterparts, that describe general job performance lations, obesity and body composition do share similar demanding environmental requirements for industrial firefighters.64 It not correlate with exercise tolerance, there factors, but as has been suggested, fatality is unclear whether additional established tools is evidence it does in firefighters.44,45 Fur- rates are likely much higher in the setting of are necessary specifically for industrial fire- thermore, in firefighters, an elevated BMI industrial fires.57 Proper tools to assess fighters. A study comparing industrial fire- limits the benefits of exercise.32 fitness-for-duty are therefore important to fighters to municipal firefighters in California Autopsy studies have linked cardio- ensure firefighters are properly equipped to found that ‘‘despite programmatic differen- megaly and left ventricular hypertrophy handle the dangers of the job while mini- ces, these departments demonstrated similar, (LVH) to sudden cardiac death in fire- mizing casualties. While studies regarding relatively high degrees of physical fitness and fighters. As a result, there have been calls firefighter fitness exist, very few focus on similar blood lipid concentrations, blood pres- for increased early detection by echocar- industrial departments. sure levels, and cardiac risk factors.’’4 How- diogram because ECG alone is a specific Prospective firefighters must pass ever, the industrial firefighter sample was test, but lacks sensitivity.46–50 Smoking, physical assessments prior to service. Sev- small (n ¼ 17). Additional studies examining CHD, hypertension, and obesity are all eral different methods currently assess fit- physiological characteristics of industrial fire- linked to LVH in firefighters.51 ness, but there are no universally accepted fighters based on NFPA standards would help Besides clinic-based testing, industrial standards across all organizations. NFPA determine if it would be beneficial to imple- fire teams can also develop other tests to publishes several codes and standards by ment additional tools specific to industrial demonstrate aerobic fitness. Several studies which many groups abide. (NFPA 1583 firefighting. have demonstrated success in matching timed provides fitness guidelines that incorporate performance in the field, (running, running measures of aerobic capacity, flexibility, WHAT PREVENTIVE with weights) with measured VO2 maxinthe muscular and endurance, and body compo- INTERVENTIONS ARE laboratory, thereby constructing simple to sition testing as part of a regular fitness administer field tests.31,52–54 Some of these regimen.58) The Candidate Physical Ability AVAILABLE AND HOW studies used absolute VO2 max cut-offs. Test (CPAT) is widely used simulation test EFFECTIVE ARE THEY? When the measured task requires the carriage for which contains eight firefighting tasks Recognizing that cardiovascular dis- of body weight, use of a relative VO2 max that mimic real-life scenarios: (1) stair ease and sudden cardiac death represent the

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single most frequent cause of duty-related Delisle et al36 proposed the potential versus volunteer firefighting, public safety fatalities in firefighters, an important ques- of a peer-mentor intervention to modify exemption for periodic examinations of tion to be considered as part of this review fitness outcomes in firefighters designated employees, and family health inquiries is, ‘‘What preventive interventions are as high risk for cardiovascular disease via a related to cardiovascular disease risk. The available and how effective are they in 3-month, high-intensity, pilot study. The safety-sensitive nature of firefighting duties reducing cardiovascular risk?’’ As with small cohort firefighters (n ¼ 29) demon- and the volunteer status of firefighters in other research questions there is a gap in strated the effectiveness of this social cog- many industrial settings potentially allow the literature specifically addressing indus- nitive theory approach to increase VO2 max for comprehensive annual fitness-for-duty trial firefighters. Therefore, this review and decrease body fat percentage versus a assessments. It is important, however, that addresses the effectiveness of wellness/fit- control group. This difference persisted at knowledgeable stakeholders, including ness programs to reduce risk factors for 1-year follow-up. The significance of this legal and human resources, be consulted cardiovascular disease and to improve car- pilot study could be that is shows the in the construct of the physical assessment diovascular capacity in the workforce in importance of involving firefighters in the process to ensure compliance with all general and in municipal firefighters spe- planning, implementation, and evaluation relevant laws. cifically as a potential surrogate for process—although, intervention costs were industrial firefighters. not considered. DISCUSSION There is abundant evidence in the The only long-term, randomized, The Task Force has undertaken an literature to support the beneficial effects prospective trial in municipal firefighters extensive literature review in an attempt to of diet and exercise to prevent cardiovascu- that was identified in the literature review provide an evidence-based guidance for lar disease. The landmark RAND study of was the PHLAME (Promoting Healthy assessing the fitness-for-duty of an indus- US employers validated the effectiveness of Lifestyles: Alternative Models’ Effects) trial brigade firefighter. This was initiated workplace wellness programs to influence Firefighter Study.67 This trial focused on due to the exclusion of industrial fire bri- beneficial changes in behavioral risk fac- nutrition, physical activity, and the mainte- gades from the very comprehensive NFPA tors for cardiovascular disease.65 The study nance of a healthy bodyweight. A team- 1582 medical standard and the paucity of reported statistically significant and clini- centric intervention group, an individual- information on the medical clearance pro- cally meaningful improvements among par- focused motivational interviewing inter- cess contained in the NFPA 600 standard, ticipants of wellness programs in exercise vention, and a control group receiving usual which is specifically intended to cover frequency, smoking behavior, and weight care were followed for 7 years. The inter- industrial fire brigades. The lack of specific control. ventions did not result in significant nor studies of industrial firefighters within the A 2013 study sampled fire depart- sustainable improvements in weight, car- medical literature excluded the possibility ments that had implemented medical and diopulmonary fitness levels, or healthy of an evidence-based guidance document. fitness programs comparable to those rec- physical activity behaviors. There was, however, sufficient information ommended in the Fire Service Joint Labor Therefore, if industrial firefighters to draw some preliminary conclusions and Management Wellness Fitness Initiative are better represented by US employees, to formulate a series of recommendations in (WFI).66 WFI recommendations included: will they be more likely to respond favor- terms of potential research opportunities as ably to worksite wellness programs as sup- well as considerations for best practice 1. NFPA 1582 compliant annual medical ported by the RAND study; conversely, will approaches to the assessment of the cardio- physical examinations to all fire service they be more resistant to workplace inter- vascular fitness of industrial firefighters. personnel ventions as suggested by the PHLAME In general, there are many similari- 2. A designated health/fitness coordinator study of municipal firefighters? It is evident ties between industrial fire brigades and 3. Peer fitness trainers from this review that inadequate attention community firefighters; however, there 4. Time for physical training/working out has been given to industrial firefighters as a are distinct differences with industrial fire- while on duty for all fire service per- group; their demographic make-up and fighters. These differences potentially place sonnel overall health status remains virtually the industrial firefighter at an elevated risk The researchers identified 10 fire unknown. It is, therefore, not possible at by virtue of the greater hazards and more departments generally meeting the WFI this time to predict the outcome of work- diverse fire types they encounter, their more recommendations and a closely matched place interventions for this group of pro- rigorous training demands, the greater lev- number of fire departments that did not fessionals. The implication is that studies els of mental stress, and a demographic of meet the criteria. There were 1002 male directed toward industrial firefighters will chronic disease, deconditioning, and obe- firefighters in the study; 522 in fire depart- be necessary to elucidate the best approach sity. Based upon responses from industrial ments aligned with WFI recommendations, to achieving sustained changes in diet and firefighters surveyed by the Task Force, and 480 not meeting recommended criteria. exercise behaviors to reduce the risk of 90% had increased, high, very high, or The study found that firefighters in depart- cardiovascular disease. extremely high risk for diabetes, hyperten- ments meeting WFI criteria were less likely sion, or coronary heart disease. How best to to be obese (adjusted odds ratio HOW DO US LAWS IMPACT quantify this risk within the setting of a [AOR] ¼ 0.58; 95% confidence interval fitness-for-duty evaluation is a main objec- [CI] ¼ 0.41 to 0.82), more likely to meet FITNESS-FOR-WORK tive of this Task Force. Risk calculators endurance capacity standards for firefight- DECISIONS? have not been validated in industrial fire- ing (AOR ¼ 5.19; 95% CI ¼ 2.49 to 10.83), This document does not address fighters, and the commonly used sub-max- and have higher estimated VO2 max Americans with Disabilities Act (ADA) imal stress tests overestimate VO2 max and (40.7 0.6 vs 37.5 1.3 for firefighters or Genetic Information Nondiscrimination as a result underestimate potential cardiac in standard departments; P ¼ 0.001). How- Act (GINA) considerations. The evaluating risk and aerobic fitness. ever, studies have found that fewer than physician needs to review federal and state A number of fitness-for-duty meth- 20% of US municipal fire departments laws and regulations related to safety-sen- odologies exist across industry, and many routinely engage in fitness programs and sitive positions, post-offer evaluation, med- do adopt the NFPA 1582 standard to assess periodic fitness-testing.32 ical accommodations, applicability of paid industrial firefighters. The presumption that

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any firefighter activities with similar peak nature of the jobs and to assess industrial facilities. NFPA J. 2002;96:26. Available demands will lead to similarly observed whether fitness practices specific at: http://www.nfpa.org/news-and-research/publi- to those areas are valid and benefi- cations/nfpa-journal/2002/november-december- adverse cardiac events suggests that indus- 2002. Accessed November 2, 2017. cial towards completing the job of trial firefighters should be screened aggres- 4. Garver JN, Jankovitz KZ, Danks JM, Fittz AA, sively for cardiac disease and aerobic an industrial firefighter in a safe and Smith HS, Davis SC. Physical fitness of an indus- capacity. One major problem with the efficient manner. trial fire department vs. a municipal fire depart- NFPA 1582 standard is that the recom- c. Investigate the demographic makeup ment. JStrengthCondRes. 2005;19:310–317. mended approach to cardiovascular screen- of industrial firefighters and include 5. Faulkner M, Levine E, Mitchell A, et al. National an assessment of their cardiovascular Response Team. Emerging Risks: Responder ing is sub-maximal stress tests (Gerkin WFI Awareness Training – Bakken Crude Oil [Power- treadmill protocol) which, as noted, over- risk profile, biometric data, and Point presentation]; 2015. Available at: https:// overall health. estimate VO2 max and, if utilized in this nrt.org/sites/2/files/NRT%20Training%20 setting, may lead to the erroneous medical d. Conduct studies to identify barriers Subcommittee%20Bakken%20Crude%20Oil% 20presentation%20V28%20scrubbed.pdf. clearance of aerobically unfit individuals to implementing sustainable health promotion programs in industrial Accessed November 2, 2017. for firefighting duties. Several studies exist 6. Vitalie T. Differences between federal, munici- that determine best practices for fire- firefighters and assess the effective- pal, and private employees. Firerecruitcom fighters’ fitness-for-duty, but none focuses ness of worksite programs in reduc- [web site]; 2009. on industrial firefighting, likely due to a ing the incidence of cardiovascular 7. Bureau of Labor Statistics, U.S. Department of lack of assessment tools specifically devel- disease. Labor. Occupational Outlook Handbook, 2016– oped for industry. e. Additional studies examining phys- 2017 ed. Firefighters [web site]. Available at: iological characteristics of industrial http://www.bls.gov/ooh/protective-service/fire- Preventive measures to reduce cardio- fighters.htm. Accessed November 2, 2017. firefighters based on NFPA stand- vascular disease risk factors and improve 8. Shelley C. Industrial and municipal fire depart- aerobic fitness are critically important for ards would help determine if it will ment interface. Fireengineeringcom [web site]; industrial firefighters; unfortunately, no be beneficial to implement addi- 2009. Available at: http://www.fireengineering.- studies exist within this population to assess tional tools and/or tests specific to com/articles/print/volume-162/issue-4/features/ industrial firefighting. industrial-and-municipal-fire-department-inter- the effectiveness of any intervention. The face.html. Accessed November 2, 2017. f. Develop and validate fitness-training only long-term, randomized, prospective 9. Centers for Disease Control and Prevention. trial in municipal firefighters identified in programs for industrial firefighters. Preventing Fire Fighter Fatalities Due to Heart this review did not result in significant nor Attacks and Other Sudden Cardiovascular In summary, industrial brigade fire- sustainable improvements in weight, cardio- Events. NIOSH publication 133; 2007. Avail- fighters share many characteristics with able at: https://www.cdc.gov/niosh/docs/2007- pulmonary fitness levels, or healthy physical municipal firefighters, but their unique job 133/pdfs/2007-133.pdf. Accessed November 2, activity behaviors. responsibilities and the physical/mental 2017. 10. Kales SN, Soteriades ES, Christoudias SG, RECOMMENDATIONS demands under which they work have not Christiani DC. Firefighters and on-duty deaths Until additional specific medical been adequately studied. The Task Force from coronary heart disease: a case control information on industrial firefighters is found gaps in the medical literature as to study. Environ Health. 2003;2:14. available, the Task Force makes the follow- demographic makeup, behavioral risk fac- 11. Kales SN, Soteriades ES, Christiani CA, Chris- tiani DC. Emergency duties and deaths from ing recommendations: tors, and burden of chronic disease, effectiveness of preventive interventions to heart disease among firefighters in the United States. N Engl J Med. 2007;356:1207–1215. enhance wellness through risk factor reduc- 1. Reference NFPA 1582 for all aspects of 12. Kales SN, Smith DL. Sudden cardiac death in the physical assessment with the excep- tion and aerobic fitness, and the proper the fire service. Occup Med (Lond). 2014;64: tion of cardiovascular fitness. methodology for a fitness-for-duty assess- 228–230. 2. Implement maximal exercise tolerance ment. Due to these gaps, the Task Force will 13. Kahn SA, Woods J, Rae L. Line of duty fire- undertake the development of a guidance fighter fatalities: an evolving trend over time. tests for the cardiovascular assessment J Burn Care Res. 2015;36:218–224. since aerobic capacity and fitness has document for industrial firefighters emu- 14. Soteriades ES, Smith DL, Tsismenakis AJ, Baur shown to be a good predictor of cardiac lating the model provided by the current ACOEM Guidance for the Medical Evalua- DM, Kales SN. Cardiovascular disease in US abnormalities as well as risk. Commonly 68 firefighters: a systematic review. Cardiol Rev. used submaximal stress tests in fire- tion of Law Enforcement Officers (LEO). 2011;19:202–215. fighters, such as the Gerkin (WFI tread- 15. Smith DL, Barr DA, Kales SN. Extreme sacri- ACKNOWLEDGMENTS fice: sudden cardiac death in the US Fire Ser- mill protocol) overestimate VO2 max. The Task Force wishes to thank vice. Extrem Physiol Med. 2013;2:6. 3. Eliminate use of submaximal stress test- reviewers Jeffrey Huth, MD, PhD, CDC/ ing as it has it has been shown to 16. Smith DL, DeBlois JP, Kales SN, Horn GP. NIOSH, and Stefanos N. Kales, MD, MPH, Cardiovascular strain of firefighting and the risk dangerously overestimate cardiovascu- Harvard Medical School & Harvard TH of sudden cardiac events. Exerc Sport Sci Rev. lar fitness. Chan School of Public Health, for their 2016;44:90–97. 4. Encourage additional follow-up research assistance, and to acknowledge ORCHSE 17. Ratchford EV,Carson KA, Jones SR, Ashen MD. in the following areas: for their work in implementing the survey. Usefulness of coronary and carotid imaging a. Develop a careful analysis of job rather than traditional atherosclerotic risk factors to identify firefighters at increased risk for car- tasks with consideration for shift- REFERENCES diovascular disease. Am J Cardiol. 2014;113: work, overtime, physical require- 1. National Fire Protection Association. Codes 1499–1504. ments for the tasks, as well as the and Standards. NFPA 1582 – Standard on 18. Byczek L, Walton SM, Conrad KM, Reichelt psychological, cognitive, and envi- Comprehensive Occupational Medical Program PA, Samo DG. Cardiovascular risks in fire- ronmental stressors for industrial for Fire Departments; 2013; 1.1.4. fighters: implications for occupational health firefighters. 2. National Fire Protection Association. Codes nurse practice. AAOHN J. 2004;52:66–76. b. Conduct studies at local sites or and Standards. NFPA 600 – Standard on Facil- 19. Geibe JR, Holder J, Peeples L, Kinney AM, ity Fire Brigades; 2013. Burress JW, Kales SN. Predictors of on-duty across a particular industrial sector 3. Klaene B, Sanders R. Expert advisors provide coronary events in male firefighters in the (eg, oil refineries, chemical strategic support: cooperation and pre-incident United States. Am J Cardiol. 2008;101: manufacturing, etc) to evaluate the planning are essential to fighting at large 585–589.

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Appendix 1: ORCHSE Survey team; volunteer community firefighter; you estimate total? Response to actual paid community firefighter; medic in fires; response to non-fire emergency; of Industrial Firefighters. community; military/other firefighter. hands on training/drills; offsite fire- Turner D, Cathcart D, 10) How would you characterize your role fighter school; classroom training; Glencross PM (2016). on the industrial fire team (select all that competitions. Unpublished Manuscript apply) fight fire in full bunker gear/ 15) If you have not had to respond to 1) How old are you (years)? 21 to 25; 26 SCBA; command and control only; actual fires in the last 3 months—have to 30; 31 to 35; 36 to 40; 41 to 45; 46 to support role only (ex. engineer/logis- you responded in the last year? Yes; 50; 51 to 55; 56 to 60; 61 to 65; 66 to tics/operations); medic; other. no. If yes, how many times? 70; 71 to 75. 11) What level of industrial responder best 16) Do you have experience as a commu- 2) Are you: male; female. describes what you do? Incipient nity firefighter? Yes; no. If yes, iden- 3) What is your height? Feet; inches. responder; exterior firefighter; struc- tify type of community: urban; 4) What is your weight (pounds)? tural firefighter; exterior/structural suburban; rural; agricultural; combi- 5) What is your waistband circumference firefighter; Hazmat operations level nation. (belt size in inches)? (defensive); Hazmat technician 17) If you have experience as a commu- 6) How many days per week do you exer- (offensive). nity firefighter, do you consider indus- cise on average? Aerobic (defined as at 12) What were the medical requirements trial firefighting to have easier least run 15 min/walk 10,000 steps/bike to be cleared for the industrial fire physical demands; the same physical 30 min/swim 30 min/other 15 min); team? (Select all that apply) Note from demands, just less frequent; harder non-aerobic (defined as walkingor sim- personal physician only; company physical demands. ilar activities that do not meet aerobic physical examination required; func- 18) If you have experience as a commu- thresholds); resistance (defined as tional capacity evaluation; treadmill or nity firefighter, do you consider indus- weight lifting /strengthening). step testing; none. trial firefighting to be more, the same 7) Where have you exercised in the last 3 13) How often are you required to be or less physically stressful; mentally months? In company gym; not in com- medically cleared for the industrial stressful; dangerous; training pany gym but on company grounds; fire team? Annually; periodically, 19) Why do you participate in the indus- outside of company; part of a fire team based upon my age; periodically, trial fire team? (Rank all the following exercise program. based upon my personal health risk and add other as appropriate.) Pay; 8) How many years total have you been factors; other teamwork; pride; part of job; chal- a firefighter? 14) Which industrial fire team activities lenge; other 9) What type of fire fighter are you now? have you participated in over the last 20) Provide any additional comments (Check all that apply) industrial fire 3 months and how many hours would regarding industrial firefighting.

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