Concentra Firefighter Physical Exam Helps Protect Our Community Protectors

Extreme physical rigor in their work – coupled with daily risk of serious or fatal injury – support the need for regular firefighter physical exams. Concentra® clinicians evaluate firefighters to determine if they are fit for duty so that fire departments can train them to respond to emergencies, scale burning structures to rescue victims, treat injured people, control and clean up hazardous oil and chemical accidents, and other essential job functions.¹ Concentra’s recommended physical exam for firefighters incorporates the 2018 updates to National Fire Protection Agency (NFPA) Standard 1582 on Comprehensive Occupational Medicine Programs for Fire Departments to help firefighters perform at their best.

What NFPA Standard 1582 currently requires

Medical testing and physical exam components outlined in NFPA 1582 conform to all relevant standards of the Occupational Safety and Health Administration (OSHA).² Specifically, this includes:

• 29 CFR 1910.120 – Hazardous waste operations and emergency response
• 20 CFR 1910.134 – Respiratory protection
• 29 CFR 1910.95 – Occupational noise exposure
• 29 CFR 1910.1030 – Bloodborne pathogens

Additionally, NFPA 1582 requirements are considered appropriate for all firefighter classifications – career firefighters, volunteer firefighters, and industrial firefighters, whether they are full-time, part-time, or on-call. While NFPA has no enforcement authority and some of the 29,705 fire departments nationwide may not follow NFPA 1582, Concentra recommends fire departments move toward the standard to help prevent injury and keep firefighters safe.³

Under NFPA 1582, firefighter should receive the following:

• Health history and physical exam
• Blood analysis (complete metabolic profile with lipid profile)
• Urinalysis
• Infectious disease screening (tuberculosis and hepatitis)
• Pulmonary function test (spirometry)
• Chest X-ray
• EKG and cardiac risk assessment
• Cancer screening
• Audiometric exam
• Vision testing
• Clinical guidance on sleep apnea
• Vaccination review/update

Medical clearance to wear a respirator and respirator fit testing are also required for firefighters and firefighter candidates.

Meaning of Category A and Category B Conditions

In a firefighter physical exam, the clinician will document the presence of any Category A and Category B medical conditions, which are defined as:

• Category A – Prevents an individual from being certified under NFPA 1582 due to a documented medical condition that precludes performance of training or emergency duties by presenting a significant risk to the safety and health of the individual or others
• Category B – Allows certification if the individual has a medical condition but can perform the essential duties of the job without presenting a significant safety risk to the individual or others

A full description of Category A and Category B medical conditions can be found in Chapter 6 of NFPA 1582. As a brief overview, disqualifying medical conditions (Category A) include: monochromatic or monocular vision, inability to wear a respirator, active pulmonary hypertension or tuberculosis, severe obstructive lung diseases, certain coronary diseases, cardiac pacemaker, hernia, uncontrolled epilepsy, and obstructive sleep apnea, if unresponsive to treatment.

What to expect in firefighter physical exams at Concentra

Concentra’s standard physical exam for firefighters consists of a health history, vital signs, vision and hearing tests, and a complete physical exam. Testing includes items in the NFPA 1582 list above, consistent with each fire department’s policy.

Concentra also has created a Human Performance Evaluation or physical fitness test in which candidates are asked to demonstrate capabilities in:

• Lifting and carrying
• Pushing and pulling
• Upper body push and pull
• Climbing
• Aerobic capacity
• Muscular strength
• Flexibility
• Endurance

A unifying driver of all services for firefighters is Concentra’s commitment to in-depth understanding of what firefighters do and the challenges they confront. We apply this knowledge in maintaining protocols for firefighter physical exams, medical surveillance, screens and tests, and we continually hone our expertise. Concentra clinicians undergo occupational health training specific to firefighters. Concentra also strives to provide convenience for fire chiefs and firefighters. We know firefighters frequently prefer to come into the center as a team and get in and out as quickly as possible. Our medical center team members seek to accomplish this whenever possible. Concentra provides fire chiefs the convenience of getting results quickly via Concentra’s Employer Portal, available 24/7.

The following sections will address four aspects of Concentra’s firefighter physical exam:

• Baseline screen and laboratory testing
• EKG and cardiac risk calculator
• Cancer screening
• Clinical guidance on sleep apnea

What to expect with laboratory screens and testing

In the baseline exam for candidates and firefighters, Concentra includes:

• General health panel (blood analysis and urinalysis)
• Hepatitis B and C antibody testing
• Tuberculosis T-Spot or skin test
• Hepatitis B vaccine series

Concentra recommends immunizations be updated as indicated in NFPA 1582 guidelines and based on the individual’s health history. A pre-placement breath alcohol test is also an available option.

For active firefighters, exams are annual and closely resemble the baseline exam. NFPA 1582 recommends specific screening, labs and testing at baseline only or specific intervals. Testing may be requested more frequently.

Concentra also provides exit exams for firefighters, which include an exit medical surveillance physical exam, general health panel, pulmonary function test, chest X-ray, EKG, and an audiogram. If a heavy metal panel is needed, Concentra can provide that, as well.

What to expect with EKG and cardiac risk calculator

Numerous research studies have investigated the cardiovascular health of firefighters. Among the conclusions are:

• Aggressive reduction of cardiovascular risk factors and improved physical fitness are needed to address cardiovascular-related deaths in the line of duty (the cause of death in 47 percent of the volunteer firefighters in the study).³
• Physical exertion and exposure to extreme heat in the midst of firefighting increases the risk of thrombus (blood clot) formation, impairs vascular function, and increases risk of acute myocardial infarction.⁴
• Coronary heart disease (CHD) is a predominant form of cardiovascular disease in the fire service and the general population. Firefighters with CHD and cardiac enlargement represent a majority of cardiac deaths in firefighting, pointing to the need for more screening.⁵

Given these and other findings concerning firefighters’ risk of cardiac disease, Concentra aligns with NFPA 1582 requirements on cardiac screening:

• An annual electrocardiogram (EKG) after age 40
• Cardio IQ® ASCVD Risk Panel with Score provides a 10-year and lifetime risk assessment of atherosclerotic cardiovascular disease. It is a blood draw that incorporates risk factors and leads to a report indicating whether an individual is at low, intermediate, or high risk for atherosclerotic cardiovascular disease. The test takes body data and family history into consideration.⁶ The 2018 NFPA 1582 recommends that ASCVD screening for firefighters over 40 be performed every two years and that firefighters under 40 with identified risk factors also be tested. This test can suggest the need for exercise tolerance testing.

What to expect with cancer screening

In a landmark study of 30,000 career firefighters from 1950 to 2009, in three urban fire settings of Chicago, Philadelphia, and San Francisco, researchers concluded that firefighters have a higher risk than the general public of being diagnosed with cancer and dying from cancer – a nine percent higher risk of diagnosis and a 14 percent higher risk of death from cancer.⁷

Two separate international studies published in 2019 explored firefighters’ risk for specific types of cancer. In one, researchers calculated significantly elevated “summary risk estimates (SIREs) for cancer of the colon, rectum, prostate, bladder, thyroid, and malignant melanoma (skin).⁸ The other found “statistically significant associations” between firefighting and non-Hodgkin’s lymphoma, skin cancer, and prostate cancer. Associations were significant but less consistent for kidney and pancreatic cancer, among others. No associations were found for a number of cancers, including esophageal, laryngeal, liver, lung, and stomach cancer.⁹

Concentra screens firefighters for six types of cancer in our medical centers:

1. Colorectal cancer (with non-invasive fecal immunochemical testing, or FIT) recommended annually after age 40 and sooner for firefighters with symptoms
2. Prostate cancer (as part of the physical exam and with a prostate-specific antigen, or PSA, test), which is recommended by age 50 – sooner if indicated by risk factors and family history
3. Skin cancer (as part of the physical exam)
4. Thyroid cancer (as part of the physical exam)
5. Bladder cancer (urinalysis)
6. Hematologic (blood) cancers (with a CBC panel, which is a complete blood cell count)

On July 7, 2018, H.R. 931 was signed into law, creating a Firefighter Cancer Registry to help monitor cancer cases and promote continued vigilance into cancer research in fire service.^{10, 11}

What to expect regarding sleep apnea

American and Australian researchers investigated associations between sleep disturbances (sleepiness and sleep deficit) and firefighter burnout, with possible mental health involvement.¹² One potentially serious sleep disturbance that affects firefighters, as well as other overtime and shiftwork occupations, is sleep apnea. Sleep apnea disturbs restful, restorative sleep, often many times a night, either by throat muscles relaxing and blocking airways (obstructive sleep apnea) or when the brain fails to send proper signals to control breathing (central sleep apnea). Firefighters who have a combination of both apnea forms are diagnosed as having complex sleep apnea syndrome.¹³

Concentra health care leaders continuously monitor research and update protocols related to excessive daytime sleepiness, obstructive sleep apnea, restless leg syndrome, and sleep disorders in general. Concentra clinicians are trained to recognize risk factors and symptoms, and use their discretion in referring a firefighter for an independent sleep study or polysomnogram; however, sleep studies are not performed in Concentra centers.

Conclusion

Firefighter physical exams aligned with NFPA Standard 1582 are the industry’s best option for firefighter health and safety. An estimated 58,250 firefighters were injured in 2018, and 27 percent (about 15,500) resulted in lost time. That same year, the NFPA estimated there were 47,150 exposures to hazardous chemicals and 6,175 exposures to infections disease.¹⁴ Steady growth in the need for firefighters is projected through at least 2028.¹⁵ Every 24 seconds, a fire department in the US responds to a fire.¹⁶ Concentra is the occupational health leader to protect your firefighters while they protect us all. Contact Concentra to learn more about firefighter physical exams, medical surveillance, respirator clearance and fit testing, cardiac risk assessments, cancer screening, and more.

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NOTES

1. Occupational Outlook Handbook: Firefighters. (Tab 1) US Bureau of Labor Statistics. Last updated: April 10, 2020.    
2. A Fire Department’s Guide to Implementing NFPA 1582. International Fire Chiefs Association. 
3. US Fire Department Profile. National Fire Protection Association. February 2020. 
4. Hunter AL, Shah ASV, Langrish JP, Raftis JB, et al. Fire Simulation and Cardiovascular Health in Firefighters. Circulation. 2017; 135(14): 1284-1295. 
5. Smith DL, Matias A. Firefighting and On-Duty Cardiac Deaths. Journal of Emergency Medical Services. November 2018.
6. Cardio IQ® ASCVD Risk Assessment Panel with Score. Quest Diagnostics. 
7. Daniels RD, Kubale TL, Yiin JH, Dahm MM, et al. Mortality and Cancer Incidence in a Pooled Cohort of US Firefighters From San Francisco, Chicago and Philadelphia (1950-2009). Journal of Occupational and Environmental Medicine. 2014; 71(6): 388-97.   
8. Jalilian H, Ziaei M, Weiderpass E, Rueegg CS, et al. Cancer Incidence and Mortality Among Firefighters. International Journal of Cancer. 2019; 145(10): 2639.  
9. Soteriades ES, Kim J, Christophi CA, Kales SN. Cancer Incidence and Mortality in Firefighters: A State-of-the-Art Review and Meta-Analysis. Asian Pacific Journal of Cancer Prevention. 2019; 20(11): 3221-3231.
10. H.R. 931 Firefighter Cancer Registry Act of 2018. Congress.gov.
11. New Firefighter Cancer Registry will help to monitor cancer incidents. July 19, 2018. US Fire Administration.  
12. Wolkow AP, Barger LK, O’Brien CS, Sullivan JP, et al. Associations Between Sleep Disturbances, Mental Health Outcomes and Burnout in Firefighters, and the Mediating Role of Sleep During Overnight Work: A Cross-Sectional Study. Journal of Sleep Research. 2019. 28(6):e12869.  
13. Sleep apnea. Mayo Clinic.  
14. Campbell R, Molis J. United States Firefighter Injuries in 2018. NFPA Journal. November 2019.  
15. Occupational Outlook Handbook: Firefighters. (Tab 6) US Bureau of Labor Statistics. Last updated: April 10, 2020. 
16. US fire problem. National Fire Protection Association.